Microsoft word - hvca&hcintake.doc
Harlem Village Community Acupuncture & Healing Center
Date:_____________
New Patient Intake Form
ALL RECORDS ARE KEPT CONFIDENTIAL
Personal Information
Name:_________________________________________
Sex: M / F / Trans ____
MTF ____
FTM
Address:_______________________________________
Birthdate:_____________
Age:______
City/State/Zip:___________________________________
Birth Place & Time:________________
Occupation:____________________________________
Height:__________
Weight:__________
Home #:___________________
Work #:_____________________
Cell#:_____________________
E-mail:_____________________
Preferred Contact: Home# / Work# / Cell# / E-mail (circle one)
Emergency Contact (Name & Phone#):_____________________________________________________
Primary Care Physician (Name & Phone#):____________________________________________
List other Health Care Practitioners treating you & for what:_____________________________
________________________________________________________________________________
Have you received acupuncture before? Y / N If yes, where, when, & for what:___________
________________________________________________________________________________
Have you received qigong therapy, essential oil therapy, tuina (Chinese massage), Chinese
herbs, Chinese dietary therapy, or any other alternative therapy before? Yes / No
If yes, which modality:_____________________________________________________________
Have you received any form of body work before? If yes, what type?______________________
________________________________________________________________________________
Medical History
Please check if you or a blood relative currently has or have experience any of the following:
Relative
Relative
Name: Date:
Harlem Village Community Acupuncture & Healing Center
Please list any other medical issue you or your blood relative has had that wasn’t listed.
________________________________________________________________________________
________________________________________________________________________________
Please list all medications you are currently taking including name, dosage, & duration.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Do you have a pacemaker? Y / N Do you have any metal parts in your body? Y / N
Are you taking Coumadin, Warfarin, or any other anticoagulant? Y / N
Are you taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs)? Y / N
Women - Gynecology
Age of first period (menarche)_____________
Age of last period (menopause)_____________
Number of days between periods________________
Number of days of flow_______________
Color of flow_______________
Clots? Y / N Color_______________
Size_______________
Discharge? Y / N When____________
Color____________
Odor? Y / N Texture___________
Are you pregnant? Y / N # of live births______ # of abortions______
# of miscarriages_______
Date of last Gyno exam______
Pap Smear______
Mammogram_____
Bone density scan______
Results of exams:_________________________________________________________________
Please check any other symptoms that you experience related to your menses.
(Indicate when you experience it; ‘B’ for before, ‘D’ for during, or ‘A’ for after your menses)
Method of contraception_____________________________
History of sexual abuse? Y / N
Name: Date:
Harlem Village Community Acupuncture & Healing Center
Do you have any issues w/ sexual intercourse? Y / N __________________________________
________________________________________________________________________________
Date of last prostate exam___________
Results________________________________________
Urinary frequency: Day___________
Night___________
Color: clear / yellow / murky / bloody
Masturbation /day________
Sex w/ ejaculation/week________
History of sexual abuse? Y / N
Do you have any issues w/ sexual intercourse? Y / N ___________________________________
Do you experience any of the following:
General Symptoms
Please mark the symptoms that you experience. (
) = sometimes experience. (+) = often experience.
____ Wakes @ night; time______ ____ Sciatica
____ Sensitive to weather change ____ Urinary problems
Name: Date:
Harlem Village Community Acupuncture & Healing Center
List any accidents, surgeries, traumas, or hospitalizations including event & date.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Life Style
Do/did you smoke? ___
cigarettes ___
pipe ___
cigars ___
marijuana ___
other_____________
How many years_______________
How much_______________
Month/years quit__________
Do you drink alcohol? Y / N Do you use street drugs? Y / N Do you take unprescribed
medications? Y / N Do you use unregulated substances, i.e. sniff glue etc.? Y / N
Please indicate what type, how much, and how often____________________________________
________________________________________________________________________________
________________________________________________________________________________
Do you drink coffee? Y / N tea? Y / N What kind______________
How many cups/day?_____
Do you drink plain water (w/ no substances added)? Y / N How many cups/day?______
Do you exercise? Y / N Type_____________________________
Frequency______________
# hours of sleep/night__________
Time you go to bed_________
Time you wake up_________
Describe your typical diet.
Breakfast________________________________________________________________________
________________________________________________________________________________
Lunch___________________________________________________________________________
________________________________________________________________________________
Dinner___________________________________________________________________________
________________________________________________________________________________
Dietary restrictions and/or allergies __________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Food cravings____________________________________________________________________
________________________________________________________________________________
Supplements/vitamins_____________________________________________________________
________________________________________________________________________________
Name: Date:
Harlem Village Community Acupuncture & Healing Center
How do you feel about these areas of your life:
Great Good Fair
Poor Bad Comments
Significant other
________________________________ ________________________________
________________________________ ________________________________
Childhood
________________________________ ________________________________
________________________________ ________________________________
Spirituality
________________________________ ________________________________
________________________________ ________________________________
Exercise
________________________________ ________________________________
________________________________ ________________________________
________________________________ ________________________________
Chief Complaint
What is your chief complaint(s)? (reason for visit) Please be detailed. ____________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
List all previous or current treatments for this condition, including medication. _____________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
List any additional information that was not asked on this form that you feel is important.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Sign indicating that you, the patient have completed this form to the best of your knowledge.
Signature _____________________________________________________
Date ___________
Name: Date:
Source: http://harlemvillageacupuncture.com/app/download/6650281704/HVCAHCintake.pdf
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