Microsoft word - healthy.body.acupuncture.consulation.form.2.doc

This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. If you have questions, please ask. Thank you. Name ______________________________________________ Date _____________ Social Security # ___________________ Home Address _____________________________________________________________________________________________ City _______________________________________________ State _______________________ Zip ____________________ Home Phone ___________________ E-mail _______________________________________ Work Phone _________________ Occupation ____________________________ Person Responsible for your account _____________________________________ Emergency Contact ________________________________________________________ Phone ___________________________ Who should we thank for referring you to this office? ______________________________________________________________ Sex: Male Female Trans ___MTF ___FTM Height _______ Weight ______ Birth date ____________ Age _____ Marital Status: Married Single Divorced Widowed Partnered Number of children _________ Have you received acupuncture therapy before? Yes No When? _______________________________ With whom? _______________________________________________________ Insurance Company __________________________________________________ Phone _______________________________ Address of Insurance Company ______________________________________________________________________________ Who is the primary insured? ________________________________________ Birth Date _______________________________ Identification # ____________________________ Policy # _______________________ Group # _______________________ Date Policy Begins ___________________ Total Yearly Deductible Individual $ ______________ Family $ ____________ Deductible Met to Date (Approx.) $ ____________________________________________________________________________ Insurance Company __________________________________________________ Phone _______________________________ Address of Insurance Company ______________________________________________________________________________ Who is the secondary insured? __________________________________________ Birth Date ___________________________ Identification # ____________________________ Policy # _______________________ Group # _______________________ Date Policy Begins ___________________ Total Yearly Deductible Individual $ ______________ Family $ ____________ Deductible Met to Date (Approx.) $ ____________________________________________________________________________ Name _____________________________________________________________ Phone _______________________________ Address of Primary Physician ________________________________________________________________________________ Assign and Release: I hereby authorize payment of medical benefits to Healthy Body Acupuncture for the services rendered to me during this and subsequent visits. I also authorize the release of any __________________________________________ information necessary to process medical claims Please indicate any significant illnesses you or a blood relative (grandparent, parent or sibling) have had: Illness Sexually Transmitted Diseases: Gonorrhea Syphilis HIV HPV Chlamydia Herpes Date _______ List any medications and supplements you are currently taking: (Continue on back if necessary.) Medicine Dosage Reason How long Prescribed by Date of last checkup _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Check the box if any of the following statements is true? I am taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs) Please indicate the use and frequency of the following: Are you pregnant? Yes No # of pregnancies _________________ # of live births ______ # of Abortions ______ # of Miscarriages ____________ Date of last: Gynecologic exam _______________ Pap Smear _______________ Mammogram ______________ Bone Density Scan _________________________ Results _____________________________________________________________ ____________________________________________________________________ Average number of pads you use per day: 1st day _____ 2nd day _____ 3rd day _____ 4th day _____ + days _________ Have you ever been diagnosed with: Fibroids Fibrocystic breasts Endometriosis Ovarian Cysts PID Other _____ Location of Pain: Lower abdomen Lower back Thighs Other_________________________________________ Nature of Pain (please indicate before, during or after menses) Dull ____________________ Bloating _______________ Bearing down sensation ____________________________ Date of last prostate check up __________ PSA results _________________ Manual prostate exam results ________________ Lab results ________________________________________________________________________________________________ Frequency of Urination: daytime ________ nighttime ________ Color of urine: clear murky odor: ______________ Symptoms related to prostate Other ___________________________________ The following is a list of symptoms that you may or may not ever experience. Please indicate as follows: no mark () = never experience check mark ( ) = sometimes experience plus sign (+) = frequently experience __ lack of appetite __ digestive problems, indigestion __ headaches ———————————————— ———————————————— ———————————————— What are the main problems for which you are What other forms of treatment have you sought? ______________________________________ ______________________________________ ______________________________________ ______________________________________ List any other health problems you now have. ______________________________________ ______________________________________ ______________________________________ ______________________________________ List any allergies, food sensitivities or food craving that you have. ______________________________________ ______________________________________ ______________________________________ ______________________________________ List any accidents, surgeries or hospitalizations (include date) ______________________________________ ______________________________________ ______________________________________ ______________________________________ Lab Results (please include copies) ______________________________________ ______________________________________ ______________________________________ How do you FEEL about the following areas of your life? Please check the appropriate boxes and indicate any problems you may be experiencing. _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

Source: http://acupunctureservicesnyc.com/clients/7447/documents/Healthy.Body.Acupuncture.Consulation.Form.pdf