Patient information

Address

1st and 2nd Child.

3rd and 4th child.

5th and 6th child.

If the patient is a minor or incapacitated, who is the legal guardian or representative accepting responsibility for care?

Emergency contact

Name of a person not living with you:

Address

Current Complaints

Main Complaint

by priority

Describe your pain from 0 up to 10 (0 no pain , 10 unbearable)

Other complaints:

Describe your pain from 0 up to 10 (0 no pain , 10 unbearable)

THINGS TO BRING WITH YOU TO YOUR FIRST APPOINTMENT:
1. "Patient information" form filled out completely.
2. Bring X-rays, laboratory reports, blood tests, doctor's reports etc.
3. Bring (in their original containers) all medications you are currently taking.
4. Bring (in their original containers) all supplements, herbs, etc. you are currently taking.

Medical History

patient symptom survey

The information you provide is strictly confidential.
Please check any condition you Now have Now (N),or have had in the Past (more than 12 months) past(P) Now and Past (N and P).

Family History

Has any member of your family had any of the above conditions?

if so which family member and what did they have?

Accidents, Falls , Broken bones

Have you ever been in a auto accident, fallen down and/or broken bones or other traumas resulting in injuries? Please list date and occurrence beginning with the most recent experience.

Surgeries, Medical Procedures

Please list them, and the dates beginning with the most recent occurrence. Have you been advised to have any surgical procedure which has not been done?

Medications,Drugs,Herbs or supplements

Please list the name, dosage and the condition for which you are taking these drugs, such as; oral contraceptives, sleeping pills, relaxants, antidepressants, antibiotics, blood pressure, heart, thyroid, or ulcer medications or any other medications. Are you allergic to any medications?

External/skeletal Exam

Head

Eyes

Nose

Ears

Neck/Throat

Shoulders

Arms, elbows, wrists and hands

Please select "R" (right), "L" (left) or "both" (both / both)

Back

Chest

Hips

Legs and knees

Ankles, feet and toes

Internal / Organ Exam

Lungs, Heart

Liver and gallbladder

Kidney and urinary bladder

Stomach, digestion and appetite

Small intestine, large intestine and rectum

Male reproductive system

Female Reproductive system

Mental, Emotional and neurological

Skin and sweating

Nutrition and lifestyles

Often people have concerns about their health but are too embarrassed or afraid to ask.

Do you have any questions or concerns about:

How do you feel about the following areas of your life ?: Please check the box that applies.

REQUEST FOR ACUPUNCTURE TREATMENT

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible).

I understand the methods of treatment may include, but are not limited to, acupuncture, cupping, electrical stimulation, Tui-Na (Chinese massage), Swedish massage, Chinese herbal medicine, and nutritional and lifestyle counseling.

I have been informed that acupuncture may have some side effects, including occasional bruising. Some bruising may also be a side effect of cupping. This clinic uses sterile one time use disposable needles.

I will notify the acupuncturist who is caring for me if I am or become pregnant, have a change in my condition or medications or have any adverse reactions to treatments.

I understand the clinical and administrative staff may review my patient records, x-rays and lab reports, and that all my records will be kept confidential and will not be released without my written consent.

I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

You have finished the ?Patient Information? form for Passport To Health. Below please enter your name, your email address, and then select the button where the form is to be sent. To the Clinic