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_____________________________
Name______________________________________________
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
taking:
Rx/Supplement/Herbs
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