chiropractic • acupuncture

Welcome to our Office

As a full spectrum office, we focus on your ability to be healthy. Our goals are, first, to address the issues that brought you to our office, and second, to offer you the opportunity to improve your health potential in the future. On a daily basis we experience physical, chemical and emotional stress that can accumulate and result in serious loss of health potential. Most times the effects are gradual and not even felt until they become serious. Answering the following questions will give us a profile of the specific stresses you have faced in your lifetime, allowing us to better assess how we can help you reach your goals.

Practice Member Information

Name____________________________________________________ Date_______________ Address____________________________________City________State_______Zip_________ Home phone_________________Work phone_______________Cell phone________________ Birth date___________________Age_________Social Security No.______________________ Email address_________________________________________________________________Marital Status: Single Married Divorced Widowed Other________________________

Occupation_____________________________Employer_______________________________ In case of emergency notify (name)_______________________Phone____________________ Person responsible for your account_______________________________________________ Insurance Co. (please give front desk copy of your card)____________________________________Referred by___________________________________________________________________How many children do you have?_________________________________________________

Present Health Challenge(s) Primary Health Concern_________________________________________________________How did this happen?___________________________________________________________How long has this been going on?_________________________________________________What makes it better?________________________________Worse?_____________________Severity (On a scale of 1-10, 10 being most severe) 1 2 3 4 5 6 7 8 9 10 Have you seen anyone else for this condition? What else have you been doing to help? (drugs, heat, ice, etc.)_________________________________________________________________

Other Health Concerns__________________________________________________________

How do these conditions impair your daily activities?__________________________________ ____________________________________________________________________________

Have you had acupuncture or chiropractic before? Y or N If so, please describe your experience:___________________________________________________________________

Chemical Stress (Please list any medications and/or supplements you are currently taking)

Drug/Supplement Reason How Long Dose Frequency ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

Use of alcohol: ___Never ___Rarely ___Moderate ___Daily Use of tobacco: ___Never ___Previously, but quit ___Current packs/day__________ Use of caffeine: ___Coffee ___Tea ___Soda How Much? ___________________ Use of drugs: ___Never ___Type/frequency____________________________________ Exposure to: ___Fumes ___Dust ___Solvents ___Airborne particles ___Noise

How many meals do you eat daily? Breakfast Lunch Dinner Snacks (Circle All That Apply)

Please rate on a scale of Poor, Good, Excellent: Diet__________ Exercise__________

Sleep__________ General Health__________

On a scale of 1-10 rate your stress level: Occupational: _____/10 Personal: _____/10

Health History (Please check if you experience any of these symptoms/conditions regularly):

___Measles ___Venereal Disease ___Blood Disorder / Transfusion ___Paralysis ___Mumps ___Epilepsy ___Vein Condition ___Stroke ___Chickenpox ___Migraine Headache ___Back trouble ___ Ulcer ___Whooping Cough ___Diabetes ___ High/Low Blood Pressure ___Kidney Disease ___Diphtheria ___Cancer or Tumor ___Hemorrhoids ___Thyroid Disease ___Smallpox ___Polio ___Asthma ___Gout ___Pneumonia ___Eye Problems ___Hives or Eczema ___Organ Transplant ___Heart Disease ___Hernia ___Bronchitis ___Bladder Infections ___Arthritis ___Eating Disorder ___Persistent Cough ___Stomach Problems ___Anemia ___Addiction ___Mitral Valve Prolapse Other________________ ___HIV+ ___Hepatitis A B C ___Tuberculosis _____________________

Previous Hospitalizations/Surgeries _______________________________________________________________When?_______________________

_______________________________________________________________When?_______________________

_______________________________________________________________When?_______________________

I am taking Coumadin/Warfarin? Y or N I have a pacemaker? Y or N

Review of Systems (Please indicate any personal history below by checking next to the symptom)

Water Element ___Cold hands/feet ___Difficulty breathing ___Neck tension Men only___Sweaty hands/feet ___Loose stools ___Shoulder tension ___Impotence ___Hot/cold intolerance ___Constipation ___Ear ringing (high) ___Prostate problems

___Blood in urine ___Gall stones ___Testicular pain ___Hot flashes ___Diarrhea ___Blurry vision ___Testicular swelling ___Night sweats ___Blood/mucous in stool ___Black spots in vision ___Cold/Numb in___Heat in chest ___Undigested food in stool ___Bloodshot eyes external genitalia ___Thirsty ___Dry eyes ___Lack of perspiration Earth Element ___Gritty eyes Women Only___Perspire easily ___Low appetite ___Breast tenderness Are you pregnant now? ___Tooth problems/cavities ___Sudden weight gain ___Brittle nails ____Yes ____No ___Easy broken bones ___Sudden weight loss ___Bloating Birth control method___ ___Sore/weak knees ___Gas ___Lump in throat ___________________ ___Cold sensation in knees ___Bloating # of children_________ ___Low back pain/weakness ___Gurgling in stomach Fire Element Ages?_______________ ___Memory Problems ___Fatigue after eating ___Palpitations ___Hair loss/ premature gray ___Prolapsed organs ___Anxiety # of abortions________ ___Low-pitched ear ringing ___Hernias ___Mouth sores # of miscarriages_____ ___Back of head headache ___Easy bruising ___Restlessness ___Kidney stones ___Hemorrhoids ___Mental confusion Age of 1st period______ ___Bladder infections ___Heaviness in limbs/body ___Chest pain Age of Menopause_____ ___Night time urination ___Mental heaviness ___Frequent dreams Last pap smear_______ ___Lack of bladder control ___Mental fogginess ___Insomnia Abnormal? Y N ___Dark &/or scanty urine ___Swollen hands/ feet ___Speech problems ___Clear &/or profuse urine ___Chest congestion # days of flow________ ___Reddish/brown urine ___Nausea Emotions # days of cycle_______ ___Cloudy urine ___Snoring ___Fears ___Strong odor of urine ___Heart burn ___Phobias Do you experience: ___Burning or painful urine ___Large appetite ___Grief ___Heavy periods ___Blood in urine ___Bad breath ___Melancholy ___Light periods ___Frequent urination ___Bleeding gums ___Anger ___Painful periods ___Sexual difficulty ___Acid regurgitation ___Worry ___Irregular periods ___High/ low libido ___Ulcer ___Over thinking ___PMS

___Belching ___Lack of joy/ humor ___Vaginal discharge ___Hiccoughs ___Laugh for no ___Infertility

Metal Element ___Stomach pain apparent reason ___Breast lumps ___General weakness ___Vomiting ___Nipple discharge ___Shortness of breath Allergy ___Vaginal discharge ___Easy to catch colds Wood Element History of reaction to: ___Fibroids ___Low energy ___Chest pain ___Antibiotics ___Endometriosis ___Feel worse after exercise ___Rib side pain ___Penicillin ___PCOS ___Nasal discharge ___Bitter taste in mouth ___Narcotics ___cramps before period ___Cough ___Depression ___Other___________ ___cramps during period ___Nose Bleeds ___Irritability ___Pain in inner thigh ___Sinus infection ___Skin rashes Known food allergies: ___Clots ___Dry mouth/ throat ___Temporal headache _________________ ___Sore throat ___Headache at top of head _________________ ___Dry skin ___Tingling sensations ___Sneezing ___Muscle cramps Release: To the best of my knowledge, the questions ___Allergies ___Muscle spasms on this form have been accurately answered. I ___Sinus Headache ___Dizziness understand that it is my responsibility to inform the ___Overall body aches ___Seizures Doctor of any changes in my health status. ___Tight neck/ shoulders ___Convulsions X Signed:_______________________________

Informed Consent for Acupuncture Treatment

I hereby request and consent to the performance of acupuncture treatments and other Oriental Medicine procedures (or the patient named below for whom I am legally responsible) by the Oriental Medicine Doctor named below and/or other Oriental Medicine Doctors who now or in the future treat me while working or associated with, or serving as a backup for the Oriental Medicine Doctor named below. Whether signatories to this form or not.I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping and gua sha, electrical stimulation, breathing techniques, exercise therapy, Tui-Na, Chinese or Western herbal therapy and nutritional counseling.I have been informed that acupuncture is a safe method of treatment, but that it may have side effects including bruising, numbness, or tingling near the needling sites that may last a few days and dizziness or fainting. I understand that I should not make significant movements while the needles are being inserted, retained or removed. Bruising is a common side effect of cupping and gua sha. Unusual and rare risk of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the acupuncturist below uses sterile, disposable needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion. I understand that while this document describes the major risks of treatment, other side effects and risks may occur.The herbs and nutritional supplements (which are from plant, mineral and animal source) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue.I understand that the herbs need to be consumed according to the instructions provided orally and/or in writing. I understand that some herbs may have an unpleasant taste or smell. I will immediately notify the Oriental Medicine Doctor of any unanticipated or unpleasant side effects associated with the consumption of herbs. I will notify the Oriental Medicine Doctor if I become pregnant.I do not expect the Oriental Medicine Doctor to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the Oriental Medicine Doctor to exercise judgement during the course of treatment, which the Oriental Medicine Doctor thinks at the time, based on facts known, and is in my best interest. I understand that results are not guaranteed.By voluntarily signing below, I show that I have read, or have had read to me, this consent to treatment, have been told about the risks and benefits of acupuncture and other procedures and have had the opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

___________________________________________ _______________________________________Print Name of Patient Print Name of Doctor

___________________________________________ _______________________________________Signature of Patient Signature of Doctor

___________________________________________Date Consent Completed