This is totally confidential and is used only for me to determine the best plan of treatment for you

Cat Calhoun, PhD, MSAOM, L Ac9999 Dont I Wish I Could Live Here Blvd, Suite 9 ( San Francisco, CA 99999Phone: (999) 999-9999 ( Fax: (999) 999-9999

New Patient Intake Form

This is totally confidential and is used only for me to determine the best plan of treatment for you. Please fill it out as completely as you can by typing in the blanks and hitting the Tab key to advance through the fields. Thanks!Personal Information

Name:Age:Todays Date:

Emergency Contact Name:Emergency Contact Phone:

Have you had acupuncture before? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, what were you treated for?

How often and how much of the following do you consume?

Water:

CoffeeSodas:

Alcohol:TobaccoIced Tea (black or green):

Artificial Sweeteners:Sugar:

Please list any prescription or over-the-counter meds you take currently. Include herbs and supplements too. Please attach a separate sheet if you need more room or just bring a list in with you for your appointment.

Medications/Herbs/SupplementsReason

Your Health History

What is the main health problem for which you are seeking treatment?

How long have you had this condition? How did it start?

What other forms of treatment have you tried?

What makes it better?

What makes it worse?

Are there any other problems youd like to tackle? 1.

2.

3.

Please check any conditions youve had in the past. Well get to current stuff on another page.

FORMCHECKBOX Addiction (drugs, food, smoking) FORMCHECKBOX COPD FORMCHECKBOX High Cholesterol FORMCHECKBOX Tonsillitis

FORMCHECKBOX AIDS FORMCHECKBOX Diabetes FORMCHECKBOX Hypertension FORMCHECKBOX Tuberculosis

FORMCHECKBOX Alcoholism FORMCHECKBOX Digestive Disorders FORMCHECKBOX HIV positive FORMCHECKBOX Typhoid Fever

FORMCHECKBOX Anemia FORMCHECKBOX Eating disorders FORMCHECKBOX Malaria FORMCHECKBOX Ulcers

FORMCHECKBOX Appendicitis FORMCHECKBOX Elevated liver

enzymes FORMCHECKBOX Measles FORMCHECKBOX Venereal Disease

FORMCHECKBOX Arteriosclerosis FORMCHECKBOX Emotional Imbalance FORMCHECKBOX Mononucleosis FORMCHECKBOX Low blood pressure

FORMCHECKBOX Arthritis FORMCHECKBOX Emphysema FORMCHECKBOX Multiple Sclerosis FORMCHECKBOX Hysterectomy

FORMCHECKBOX Asthma FORMCHECKBOX Epilepsy FORMCHECKBOX Mumps FORMCHECKBOX Kidney problems

FORMCHECKBOX Bladder disease FORMCHECKBOX Fibromyalgia FORMCHECKBOX Nephritis FORMCHECKBOX Depression

FORMCHECKBOX Breast lumps FORMCHECKBOX Food, chemical or drug poisoning FORMCHECKBOX Neuralgia FORMCHECKBOX Mental disorders

FORMCHECKBOX Breathing problems FORMCHECKBOX Gall stones FORMCHECKBOX Paralysis FORMCHECKBOX Suicidal thoughts

FORMCHECKBOX Bulemia FORMCHECKBOX German measles FORMCHECKBOX Polio or meningitis

FORMCHECKBOX Bursitis FORMCHECKBOX Glaucoma FORMCHECKBOX Prostate problems

FORMCHECKBOX Cancer FORMCHECKBOX Goiter FORMCHECKBOX Rheumatism

FORMCHECKBOX Candida FORMCHECKBOX Gout FORMCHECKBOX Scarlet fever

FORMCHECKBOX Chicken pox FORMCHECKBOX Heart disease FORMCHECKBOX Small pox

FORMCHECKBOX Chronic fatigue FORMCHECKBOX Hernia FORMCHECKBOX Stroke

FORMCHECKBOX Colitis/bowel disease FORMCHECKBOX Hepatitis FORMCHECKBOX Thyroid problems

Surgeries:

Significant Traumas (Accidents, disasters, death of loved ones):

Allergies:

What kind of regular exercise do you do?

Do you have any kind of occupational stress? If so, please describe:

Your Family Medical History

Please check all that apply

FORMCHECKBOX Diabetes FORMCHECKBOX Cancer FORMCHECKBOX Breast Cancer FORMCHECKBOX High blood pressure FORMCHECKBOX Low blood pressure

FORMCHECKBOX Asthma

FORMCHECKBOX Allergies FORMCHECKBOX Alcoholism or addictions FORMCHECKBOX Hysterectomy FORMCHECKBOX Prostate problems

FORMCHECKBOX Heart Disease

FORMCHECKBOX Kidney disorders FORMCHECKBOX Stroke FORMCHECKBOX Depression,

emotional

disorders FORMCHECKBOX Suicide

Your Symptoms and Current Medical StatusPlease place a checkmark next to any symptom or conditions you have now or experience frequently.

FORMCHECKBOX Loose stools or diarrhea FORMCHECKBOX Indigestion FORMCHECKBOX Nausea or vomiting FORMCHECKBOX Acid reflux

FORMCHECKBOX Belching FORMCHECKBOX Varicose veins FORMCHECKBOX Anemia FORMCHECKBOX Bruise easily

FORMCHECKBOX Lack of appetite FORMCHECKBOX Diabetes or hypoglycemia FORMCHECKBOX HIV positive or AIDS FORMCHECKBOX Sweat easily

FORMCHECKBOX Feeling of reten-

tion of food in stomach FORMCHECKBOX Prolapsed organs FORMCHECKBOX Eating disorder FORMCHECKBOX Suicidal feelings

FORMCHECKBOX Tendency to become obsessive in work or relationships

FORMCHECKBOX Insomnia. Time? FORMCHECKBOX Heart palpitations FORMCHECKBOX Restlessness

FORMCHECKBOX Nightmares or sleep disturbed by dreams FORMCHECKBOX Anxiety attacks FORMCHECKBOX Easily startled FORMCHECKBOX Chest pain

FORMCHECKBOX Racing of heart

FORMCHECKBOX Irregular heartbeat FORMCHECKBOX Arthritis FORMCHECKBOX Poor vision

FORMCHECKBOX Headaches/migraines. Where are they usually and when do you get them?

FORMCHECKBOX High/low blood pressure FORMCHECKBOX Cataracts FORMCHECKBOX Spots before eyes

(floaters) FORMCHECKBOX Ringing in ears

FORMCHECKBOX Dizziness FORMCHECKBOX Gallstones FORMCHECKBOX Shingles FORMCHECKBOX Herpes

FORMCHECKBOX Eczema FORMCHECKBOX Shoulder or neck tension FORMCHECKBOX Sciatica FORMCHECKBOX Impatience

FORMCHECKBOX Difficult bowel movements FORMCHECKBOX Hemorrhoids FORMCHECKBOX Hepatitis FORMCHECKBOX Soft or brittle nails

FORMCHECKBOX Depression FORMCHECKBOX Fullness behind the ribs FORMCHECKBOX Indecisiveness FORMCHECKBOX Easily angered

FORMCHECKBOX Cough FORMCHECKBOX Bronchitis FORMCHECKBOX Sadness FORMCHECKBOX Shallow breathing

FORMCHECKBOX Sinus congestion,

frequent infections FORMCHECKBOX Asthma FORMCHECKBOX Sore throat FORMCHECKBOX Shortness of breath

FORMCHECKBOX Weak voice FORMCHECKBOX Constipation FORMCHECKBOX Recent use of antibiotics FORMCHECKBOX Emphysema

FORMCHECKBOX Nasal discharge: FORMCHECKBOX Clear FORMCHECKBOX White FORMCHECKBOX Yellow FORMCHECKBOX Green FORMCHECKBOX Bloody FORMCHECKBOX Thick FORMCHECKBOX Thin/watery

FORMCHECKBOX Skin problems:

FORMCHECKBOX Hearing loss FORMCHECKBOX Low back pain FORMCHECKBOX Weak or sore knees FORMCHECKBOX Edema or swelling

FORMCHECKBOX Hair loss FORMCHECKBOX Prostate disorders FORMCHECKBOX Impotence FORMCHECKBOX Urinary disorders

FORMCHECKBOX Osteoporosis FORMCHECKBOX Teeth/gum problems FORMCHECKBOX Reduced sexual energy FORMCHECKBOX Fearfulness

FORMCHECKBOX Spontaneous sweating FORMCHECKBOX No energy to speak FORMCHECKBOX Lack of strength

FORMCHECKBOX Dislike of physical movement FORMCHECKBOX General physical weakness FORMCHECKBOX General fatigue

FORMCHECKBOX Blurred vision FORMCHECKBOX Dry, brittle hair FORMCHECKBOX Poor memory FORMCHECKBOX Skin rashes

FORMCHECKBOX Numbness (where):

FORMCHECKBOX Aversion to cold FORMCHECKBOX Cold hands and feet FORMCHECKBOX Easily chilled

FORMCHECKBOX Frequent clear urination FORMCHECKBOX Lack of thirst FORMCHECKBOX Desire for hot drinks FORMCHECKBOX Desire for cold drinks

FORMCHECKBOX Frequently thirsty FORMCHECKBOX Hot hands and feet FORMCHECKBOX Night sweats

FORMCHECKBOX Low-grade afternoon fever

FORMCHECKBOX Dry throat FORMCHECKBOX Red, flushed cheeks

FORMCHECKBOX Other:

Pain Patients

After you complete this form, print it out and shade or circle the areas where you feel pain.

How would you characterize your pain?

FORMCHECKBOX Dull or achy FORMCHECKBOX Sharp or stabbing FORMCHECKBOX Burning FORMCHECKBOX Tingling FORMCHECKBOX Numbness FORMCHECKBOX Electrical shock

Gynecological InformationAny possibility you are pregnant? FORMCHECKBOX Yes FORMCHECKBOX NoBirth control:

Number of: Pregnancies: Births: Miscarriages: Abortions:C-Sections:

PAP

Date of last PAP:Pap results:

Vaginal sores?

Menstrual flow (skip it if youre in menopause and no longer bleeding):

FORMCHECKBOX Heavy FORMCHECKBOX Light FORMCHECKBOX Clots FORMCHECKBOX Painful

Color of Menses:# Days between periods:

Length of period:Date of last period:

Age of 1st period:Spotting between periods:

PMS

FORMCHECKBOX Breast soreness FORMCHECKBOX Bloating FORMCHECKBOX Moodiness FORMCHECKBOX Irritability

FORMCHECKBOX Cramps FORMCHECKBOX Other: ____

Perimenopause FORMCHECKBOX Skipped or

irregular periods FORMCHECKBOX Hot flashes FORMCHECKBOX Moodiness FORMCHECKBOX Vaginal dryness

FORMCHECKBOX Age at menopause: FORMCHECKBOX Hysterectomy age/reason:

FORMCHECKBOX Vaginal Discharge (describe):

FORMCHECKBOX Breast lumps

or cysts: FORMCHECKBOX Endometriosis (when):

FORMCHECKBOX Other:

Final Bits

Favorite season: Least favorite season:

How would you describe your overall emotional state?

Anything else youd like to discuss:

For Your InformationPlease read following:

1. I only use sterile, disposable needles.

2. Occasionally acupuncture can leave a small hematoma (bruise under the skin). This is not a cause for concern as it will go away in a few days. Gentle pressure applied at the site will stop any small amount of bleeding that is occurring under the skin.

3. If I recommend herbs for you, I am recommending them for you and not for anyone else. Please dont give your herbal prescriptions to anyone else! 4. After receiving acupuncture treatment you might feel a little lightheaded (and sometimes euphoric). Please feel free to have a seat, drink a little water and relax to let yourself come back to normal. In a few minutes you will feel relaxed and clear headed.

5. You may be asked to see a physician or chiropractor for your condition if needed. Please do so if it is within your means. I will only ask this of you when I believe it to be necessary.

6. All fees are payable prior to your treatment. Informed Consent to TreatmentI, the undersigned, hereby request and consent to treatment by acupuncture and/or other procedures within the scope of the practice of acupuncture. Methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, guasha, herbal therapy, bodywork, Reiki and medical Qigong.I am hereby informed that the aforementioned treatment methods are all generally safe but that there may be some side effects or risks, as follows:

Acupuncture may potentially cause temporary bruising, swelling, bleeding, numbness and tingling, or soreness at the site of needling. Unlikely risks of acupuncture include lung puncture (pneumothorax), nerve damage, organ puncture, and infection - although I use only sterile, disposable needles and maintains a clean and safe environment.

Potential risks of moxibustion include blistering, burns, and scarring. Common side effect of cupping and gua sha are temporary bruising and redness lasting a few days.

The herbal and nutritional supplements (which may be from plant, animal, or mineral sources) recommended to me are generally safe in the traditionally recommended doses. Possible side effects of herbs include nausea, gas, stomache ache, diarrhea, and headache. Unusual side effects of herbs include vomiting, rashes, hives, and tingling of the tongue. I understand I must stop taking any herbs and notify my acupuncturist if I experience any discomfort or adverse reaction.

I will notify the acupuncturist should I become pregnant or if I am in the process of trying to get pregnant as certain acupuncture points and herbs are contraindicated during pregnancy and could induce miscarriage.

I understand that I can discuss risks and benefits further before signing if I so choose, although I do not expect my practitioner to be able to anticipate and explain all possible risks and complications of treatment. I rely on my practitioner to exercise her judgment in my best interest during the course of treatment, based upon the facts then known.

I fully understand that there is no implied or stated guarantee of success or effectiveness of a specific treatment or series of treatments. I understand that my practitioner will keep all of my records confidential.In signing this form, I acknowledge any inherent risks, and give my consent for treatment; healthcare operations received, incurred or carried out by my practitioner.

__________________________________________________________________________________________

Signature of Person being treated

Date

Green World Family Clinic

Patient Intake Form Page 1 of 8