Acupuncture Intake - Patient Information Form Page 4
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4Acupuncture Intake
Sores on lips or tongue
Headaches (where and when)___________________________
Other head or neck problems____________________________________________________
CARDIOVASCULAR
High blood pressure
Low blood pressure
Chest pain
Irregular heartbeat
Dizziness
Fainting
Cold hands/feet
Swelling in hands/feet
Blood clots
Phlebitis
Difficulty breathing
Other__________________
RESPIRATORY
Cough
Coughing blood
Asthma
Bronchitis
Pneumonia
Difficulty breathing when lying down
Tight chest
Production of phlegm (color) ___________________
GASTROINTESTINAL
Nausea
Vomiting
Diarrhea
Bowel movements:
Gas
Belching
Black stools
_________Frequency
Bad breath
Rectal pain
Hemorrhoids
_________Color
Constipation
Bloody stools
Sensitive abdomen
_________Odor
Pain or cramps Laxative use __________/week; type ____________________Texture/form
GENITO-URINARY
Pain on urination
Frequent urination
Blood in urine
Urgency to urinate
Unable to hold urine
Kidney stones
Venereal disease
Impotency
Wake up to urinate _________/night; time __________
PREGNANCY AND GYNECOLOGY
Number pregnancies_____
Age at first menses______
Flow __________
Clots
Vaginal discharge
Period (days)___________
Duration_______________
Last menses____________
Menopause_____________
Last PAP______________
Number births__________
Premature births________
Miscarriages___________
Breast lumps
Vaginal sores
Birth control: type and duration______________________________________________________
Changes in body/psyche prior to menstruation__________________________________________
MUSCULSKELETAL
Neck pain
Muscle pains
Back pain (where)_______________________________
Joint pain (where)_____________________
Other joint or bone problems________________
NEUROPSYCHOLOGICAL
Seizures
Areas of numbness
Poor memory
Concussion
Depression
Anxiety
Bad temper
Easily stressed
Treated for emotional problems____________________________________
Considered/attempted suicide
Other neurological or psychological problems__________________________________________
PREFERENCES
Season: Most liked_________________ Least liked____________________
Taste: Most liked__________________ Least liked_____________________
Climate: Most liked________________ Least liked___________________
Time of Day: Most liked_________________ Least liked________________
Temperature: Most liked_________________ Least liked_______________
PATIENT NAME:_____________________________________________________
PATIENT DOB:____________________________
KWAN-YIN HEALING ARTS CENTER
2330 NW FLANDERS ST. SUITE 101
PORTLAND, OR 97210
PH: 503.701.8766
FAX: 503.241.5484
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