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