Acupuncture Intake Form Page 5
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6Genito-Urinary
O
O
O
Bed wetting
Urgent urination
Libido issues
O
O
O
Bladder infections
Wake to urinate
Yeast infection
O
O
O
Bloody urine
Pale urine
Impotence
O
O
O
Frequent urination
Dark urine
Prostate Disorder
O
O
O
Painful urination
Cloudy urine
Premature ejaculation
O
O
O
Incomplete urination
Kidney stones
Nocturnal emissions
O
O
Incontinence
Kidney Disease
O
Other: __________________________________________________________________________
Gynecological
PMS – headaches
O
O
O
Menopause
Genital discharge
PMS – back aches
O
O
O
Oral Birth control pills
Genital swelling
PMS – mood swings
O
O
O
Intra-Uterine Device IUD
Hysterectomy
O
O
O
Breast lumps
Endometriosis
# Pregnancies ________
O
O
O
Genital burning
Fibroids
# Miscarriages_________
O
O
Genital itching
Cysts
Menstruation Information:
Describe the menstrual blood:
O
O
O
Heavy periods
Pain After
Thin/Watery
O
O
Light periods
Very thick
O
Dark Red
O
O
Irregular periods
Clots?
O
Bright Red
O
o Size ________
Pain Before
O
Pale Red
o Color ________
O
Pain During
O
Brownish
# Days between periods __________ # days of period__________
Other Information: _________________________________________________________________________
Skin and Hair
O
O
O
Acne
Fungal infection
Itchy/dry skin
O
O
O
Burning skin
Hair loss
Psoriasis
O
O
O
Dandruff
Hot flashes
Rashes
O
O
O
Dermatitis
Heavy sweating
Shingles
O
O
O
Discolorations
Not able to sweat
Warts
O
O
Eczema
Hives
O
Other: __________________________________________________________________________
Neuro-Psychological
O
O
O
ADD/ADHD
Epilepsy
Poor coordination
Parkinson’s �� D isease ��
O
O
O
Addiction
Irritability
O
O
O
Anxiety
Mental illness
Poor memory
O
O
O
Depression
numbness
Seizure
“Foggy” �� f eeling ��
O
O
O
Easily stressed
Vertigo/Dizziness
O
Other: __________________________________________________________________________
Musculoskeletal:
O
O
O
Osteoarthritis
Limited motion
Neck pain
O
O
O
Rheumatoid arthritis
Limited use
Rib pain
O
O
O
Atrophy
Back pain
Scoliosis
O
O
O
Body heaviness
Muscle pain
Weight gain
O
O
O
Joint pain
Muscle cramps
Weight loss
O
Broken Bones: ___________________________________________________________________
O
Other: ______________________________________________________________________
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