Rachal lohr dean, l

South Riding Acupuncture
4080 Lafayette Center Drive, Suite 320
This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you.
__________________________Personal Information_____________________________
Home Address_______________________________________ State ______ Zip ________ Home Phone ________________ Work _____________ Cell Phone ________________ Occupation _____________ Your Preferred Email ______________________________ Emergency Contact ____________________________ How did you hear of us:  Website  Family Member Friend  Acupuncture.com Yelp.com Physician/Chiropractor May we thank someone in particular? _________________________________
Sex: M F Height: _______ Weight ______ Birth Date: _________ Age: ______
Marital Status: Married Single Divorced Widowed ___Number of Children
Previous Acupuncture? Yes No When? ___________ With Whom? ___________
Please indicate the use and frequency of the following:

Yes No Amount
Yes No Amount Yes No Amount
Tobacco  _______ Water  ________ Alcohol   _______ Soda  ________

Please Check the Box if any of the following statements are true:

I have known allergies: Yes No
I am taking Coumadin/ Warfarin/ Plavix: Yes No I am taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs) Yes No
I have a history of fainting or seizures Yes No

Physician History

Have you seen a physician in the last year?  Yes  No If yes:
Physician’s Name: _________________________________ Phone: ________________________
Approximate date of most recent examination/visit? _____________________________________

What is your Chief health Complaint?
Do you have any additional health concerns?

South Riding Acupuncture
4080 Lafayette Center Drive, Suite 320 Medications: Please list any prescription or OTC medications or supplements and herbs you are currently
Reason for
Prescribed by? Date of last
taking the
check up?
List any allergies, food sensitivities you have. _____________________________________________________________________ _____________________________________________________________________ List any accidents, surgeries or Hospitalizations (include date). _______________________________________________________________________ _______________________________________________________________________ ______________________________________For Women________________________________________________ Age of 1st period (menarche) ___________ Are you pregnant? Yes  No Age of Last Period (menopause) ________ # of live births ______ # of Abortions ______ # of Miscarriages ______ Number of days between Periods _______ Date of last: Gynecologic exam ____________ Number of days of flow ______________ Mammogram ______________ Color of flow _______________________ Results _____________________________________________________ Clots? Yes  No Color ___________ _____________________________________________________ Average number of pads you use per day: 1st day ____ 2nd Day ____ 3rd Day ____ 4th day ____ +days _________ First Day of Last Period: Have you been diagnosed with: Fibroids Fibrocystic Breasts Endometriosis Ovarian Cysts PID Other ___________________ Location of Pain: Lower Abdomen (Please indicate before, during or after Menses) Poor AppetiteHot flashes Night sweats Bearing down sensation ______________________ Ravenous appetite Decreased libido South Riding Acupuncture
4080 Lafayette Center Drive, Suite 320 ________________________________________For Men________________________________________________ Date of last prostate check up __________ PSA results ____________ Manual prostate exam results ___________ Lab results ______________________________________________________________________________________ Frequency of Urination: daytime ________ nighttime ________ Color of urine: clear murky Symptoms related to prostate: Prostate problems Delayed stream Rectal dysfunction Increased libido Decreased libido Premature ejaculation Other __________________________________ _______________________________Symptom Survey (for Everyone)_____________________________________ The following is a list of symptoms that you may or may not ever experience. Please indicate as follows: check mark()= sometimes plus sign (+) = frequently experience -------------------------------
__laughing for no apparent reason __hemorrhoids

Source: http://www.southridingacupuncture.com/Patient_Information_Form-_PDF.pdf

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