I. Goals: What would you most like to achieve through your work at Twelve Pathways Acupuncture?
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1 NAME DATE I. Goals: What would you most like to achieve through your work at Twelve Pathways Acupuncture? II. Major Symptoms: Please list in order of importance what symptoms are of concern to you. (most concerning to least, along with the duration of the symptom) Use the following illustration to indicate painful or distressed areas: Are you experiencing pain/discomfort in any area of your body? Y / N If yes, using the models to the left, please indicate the location of the discomfort by using the symbol that best describes the feeling: X X X Sharp/ Stabbing P P P Pins & Needles D D D Dull/Aching N N N Numbness For Women: 1. Are you pregnant now? [ ]Yes [ ]No [ ]Unsure 2. Indicate number of occurrences: rences: Live Births Pregnancies Miscarriages Abortions 3. Age: First period Menopause (if applicable) 4. Date: Last Pap Smear / Last Mammogram / 5. Any History of an Abnormal Pap Smear? [ ] Yes [ ] No If so, what / when? 6. Is your menses cycle regular? [ ] Yes [ ] No a) Average number of days of flow b) The flow is: [ ] Normal [ ] Heavy [ ] Light c) The color is: [ ] Normal [ ] Dark [ ] Purple [ ] Light Brown [ ] Brown
2 7. Do you have the following menstruation related signs/symptoms? [ ] Difficulty with Orgasm [ ] Cramps [ ] PMS [ ] Heavy vaginal discharge between periods [ ] Pain with Intercourse [ ] Nausea [ ] Bleeding between Periods [ ] Blood Clots [ ] Breast Distention [ ] Vaginal Discharge For Men: 1. Do you have any bothersome urinary symptoms? [ ] Yes [ ] No Describe: 2. Check all that apply: [ ] Erectile dysfunction [ ] Difficulty with orgasm [ ] Pain or swelling of the testicles [ ] Frequent need to urinate at night [ ] Impotence/erectile dysfunction [ ] Premature ejaculation [ ] Feeling of coldness or numbness in genitalia [ ] Pain/Subtly of testicles 3. Do you get up at night to urinate? [ ] Yes [ ] No How often? 4. To what extent do these conditions interfere with your daily activities (work, sleep, socializing, sex, etc.)? 5. Have you sought Medical intervention for these problems? If so, when? 6. What treatments have you tried for these problems and how successful have they been? III. Medical History Please add date diagnosed to all that apply: Diabetes / / High Cholesterol / / High Blood Pressure / / High Blood Pressure / / Thyroid Disease / / Seizures / / Cancer / / Hepatitis / / HIV / / Others / / IV. Surgical History
3 V. Family History Please check all that apply and state how you are related to the family member with that condition. VI. Medications / Supplements Medications you are currently taking (please include prescription medicine, supplement, herbal supplements and over the counter medicines you take on a regular basis, along with dosages and brands if known) Allergies (to medications, chemicals or foods): VIII. Nutrition 1. Do you follow a special diet? [ ] Yes [ ] No If yes, how would you describe the diet? (ie Vegetarian, Vegan, Low Carb, etc.) 2. What do you eat on a typical day? a) Breakfast b) Lunch c) Dinner d) Snacks e) Foods you tend to crave: f) Foods you dislike:
4 IX. Social History 1. How much per day do you use of the following? a) Coffee, tea, soft drinks: b) Alcohol: c) Cigarettes, cigars, other tobacco: d) Other drugs: 2. Have you ever had a problem with alcohol or alcoholism? [ ] Yes [ ] No 3. Have you ever had a problem with dependency on other drugs? [ ] Yes [ ] No 4. If yes which and when? 5. Do you have a known history of any exposure to toxic substances? [ ] Yes [ ] No 6. If so, please list which and when you first noticed symptoms? 7. In the past year, how many days have been significantly affected by your health? 8. How many days did you feel generally poor? 9. How many times were you in the hospital? 10. Please describe your current exercise regimen: Hours per week: Activities: [ ] No Exercise 11. How many hours of sleep do you usually get per night during the week? 12. Do you awake feeling rested? [ ] Yes [ ] No Do you feel you sleep well at night? [ ] Yes [ ] No 13. Who would you describe as your source of primary social support? (relationship to you) X. Other Information Please list and briefly describe the most significant events in your life: Have you been treated for emotional issues? [ ] Yes [ ] No Have you ever considered or attempted suicide? [ ] Yes [ ] No Do you have any other neurological or psychological problem? [ ] Yes [ ] No Please provide us with any other information that you think is relevant for us to know:
5 HEALTH: CHECK ALL THAT APPLY GENERAL Past Current Condition SKIN & HAIR [ ] [ ] Poor appetite Past Current Condition [ ] [ ] Excessive appetite [ ] [ ] Rashes [ ] [ ] Insomnia [ ] [ ] Hives [ ] [ ] Fatigue [ ] [ ] Itching [ ] [ ] Fevers [ ] [ ] Eczema [ ] [ ] Night sweats [ ] [ ] Pimples [ ] [ ] Sweat easily [ ] [ ] Dryness [ ] [ ] Chills [ ] [ ] Tumors, lumps [ ] [ ] Localized weakness [ ] [ ] Other: [ ] [ ] Poor coordination [ ] [ ] Bleed or bruise easily [ ] [ ] Catch cold easily [ ] [ ] Strong thirst [ ] [ ] Other: EYES NOSE [ ] [ ] Blurred vision [ ] [ ] Nose bleeds [ ] [ ] Visual changes [ ] [ ] Sinus infections [ ] [ ] Cataracts [ ] [ ] Hay fever or allergies [ ] [ ] Sports [ ] [ ] Other: [ ] [ ] Eye inflammation [ ] [ ] Poor night vision [ ] [ ] Glasses / contacts [ ] [ ] Other: BACK & NECK EARS [ ] [ ] Dizziness [ ] [ ] Infection [ ] [ ] Stiff neck [ ] [ ] Ringing [ ] [ ] Enlarged lymph glands [ ] [ ] Decreased hearing [ ] [ ] Headaches [ ] [ ] Other: [ ] [ ] Concussions [ ] [ ] Fainting [ ] [ ] Other: CARDIOVASCULAR THROAT & MOUTH [ ] [ ] High blood pressure [ ] [ ] Grinding teeth [ ] [ ] Low blood pressure [ ] [ ] Recurring sore throats [ ] [ ] Blood clots [ ] [ ] Difficulty swallowing [ ] [ ] Palpitations [ ] [ ] Phlebitis [ ] [ ] Irregular heart beat [ ] [ ] Cold hands / feet [ ] [ ] Fainting [ ] [ ] Difficult breathing [ ] [ ] Swelling of hands / feet [ ] [ ] Other
6 GENITO-URINARY GENI RESPIRATORY URINARY GENITO -URIN GENITO - URINARY Past Current Condition [ ] [ ] Asthma Past Current Condition [ ] [ ] Bronchitis [ ] [ ] Kidney stones [ ] [ ] Frequent colds [ ] [ ] Urination pain [ ] [ ] Chronic obstructive [ ] [ ] Urination frequency [ ] [ ] Pulmonary disease [ ] [ ] Blood in urine [ ] [ ] Pneumonia [ ] [ ] Urgency to urinate [ ] [ ] Cough [ ] [ ] Unable to hold urine [ ] [ ] Production of phlegm [ ] [ ] Other: [ ] [ ] Other: GASTRO- INTESTINAL INFECTION SCREENING [ ] [ ] Nausea [ ] [ ] HIV [ ] [ ] Vomiting [ ] [ ] TB [ ] [ ] Diarrhea [ ] [ ] Hepatitis [ ] [ ] Hemorrhoids [ ] [ ] Gonorrhea [ ] [ ] Pain and cramps [ ] [ ] Chlamydia [ ] [ ] Constipation [ ] [ ] Syphilis [ ] [ ] Rectal pain [ ] [ ] Genital warts [ ] [ ] Belching [ ] [ ] Herpes: oral [ ] [ ] Gas [ ] [ ] Herpes: genital [ ] [ ] Indigestion [ ] [ ] Other: [ ] [ ] Gall bladder disorder [ ] [ ] Blood in stools [ ] [ ] Bad stools [ ] [ ] Bad breath [ ] [ ] Other: FEMALE MALE [ ] [ ] Frequent urinary tract infections [ ] [ ] Pain /itching genitalia [ ] [ ] Frequent vaginal infections [ ] [ ] Genital lesions/discharge [ ] [ ] Pain/itching of genitalia [ ] [ ] Impotence [ ] [ ] Genital lesions/discharge [ ] [ ] Weak urinary stream [ ] [ ] Pelvic inflammatory disease [ ] [ ] Lumps in testicles [ ] [ ] Abnormal pap smear [ ] [ ] Other: [ ] [ ] Irregular menstrual periods [ ] [ ] Painful menstrual periods [ ] [ ] Premenstrual syndrome PSYCHOLOGICAL [ ] [ ] Abnormal bleeding [ ] [ ] Depression [ ] [ ] Menopausal syndrome [ ] [ ] Anxiety/stress [ ] [ ] Breast lumps [ ] [ ] Irritability [ ] [ ] Hot flashes [ ] [ ] Treated for emotional or [ ] [ ] Menopausal syndrome [ ] [ ] Psychological problems [ ] [ ] Other: [ ] [ ] Other: MUSCULAR SKELETAL NEUROLOGICAL [ ] [ ] Stiff neck / shoulders [ ] [ ] Seizures [ ] [ ] Low back pain [ ] [ ] Tumor [ ] [ ] Back pain [ ] [ ] Pain [ ] [ ] Muscle spasm [ ] [ ] Numbness/tingling of limbs [ ] [ ] Muscle twitching, cramps [ ] [ ] Concussion [ ] [ ] Sore, cold or weak knees [ ] [ ] Paralysis [ ] [ ] Joint Pain [ ] [ ] Other: [ ] [ ] Other:
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