Patient Medical History & Intake Form
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- Marsha Strickland
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1 Anita Lang- Bakar, L.Ac Buchanan Street, Suite 204 San Francisco, CA Patient Medical History & Intake Form Name Date Street Address Apt. # City State Zip Home Phone Office Phone Other Phone E- mail Birth Date Age Soc. Sec. Gender Single Married Divorced Widowed Domestic Partnership Other Referred to out Clinic by: Emergency Contact Relationship Emergency Contact Phone Office/Cell Physician s Name Phone Physician s Address Date of last visit Employment: Please check all that apply Full- time Part- time Self- employed Student Unemployed Retired Occupation: Number of hours of work/study per week Employer s Name: Phone #: Employer s address Billing and Insurance Account Paid by Self Workmen s Comp Other Primary Insurance Company: Tel#: Primary Insurance Address Policy Holder s Name Relationship Policy# / ID Group # Secondary Insurance Company: Tel#: Policy# / ID Group # 1
2 Have you ever had an acupuncture treatment? When and for what reason? Are you presently being treated for a medical condition? Please describe. What health issue(s) do you want to be treated for? Please describe as fully as possible. What treatment (if any) have you been using for relief of this issue? Do you have other health concerns? If so, please describe. Please describe the types of foods you eat regularly at each meal and during the day: Breakfast Lunch Dinner Snacks/other meals Do you Exercise Regularly? Yes No How Frequently? times per day / week What type of Exercise do you do? Let us know how you feel about the following areas of your life. Please mark the appropriate description and indicate any problems you may be experiencing: Spouse/Partner Family Diet Sex Self Work Habits - Please check any habits that apply to you now or in the past Coffee Yes No cups per day/week: age started age quit Tobacco Yes No cigarettes per day/week: age started age quit Alcohol Yes No Drinks per day/week: age started age quit Cocaine Yes No use per day/week age started age quit Heroin Yes No use per day/week age started age quit Marijuana Yes No use per day/week age started age quit Other: 2
3 Family History - Please check all that are appropriate by marking with an X Allergies Blood disorder/anemia Diabetes Cancer or Tumors Seizures High Blood Pressure Kidney or Bladder disorder Stomach or intestinal disorder Drug Abuse Tuberculosis Heart Disease Stroke Depression/Mental Illness Other Age at death Self Mother Father Sister Brother Child Grandparent Major Hospitalizations - Please list any hospitalizations or surgeries you have undergone. Year Operation or illness Name of Hospital City & State Medicines, Herbs and Supplements - Check any medications you are currently taking Aspirin Ibuprofen (Advil) Acetaminophen (Tylenol) Antacids Laxatives Cold tablets Allergy Medicine Diet Pills Tranquilizers Sleeping Pills Oral contraceptives Blood pressure Pills Blood thinning medication Insulin/diabetes pills Fiber Supplements Other: (Please List name of drug & Dosage) Vitamins & Supplements (Please List) Herbs (Please List) Allergies Yes No Carry EpiPen To Medication: To Food: Latex or other: 3
4 Symptoms/Concerns Please mark all that apply Musculo- Skeletal Injury Past Current: Location Joint Pain Muscular Pain Strain Past Current: Location Broken Bone(s) Atrophy Localized Weakness Numbness/Tingling of Limbs Area of Pain (Please circle the area of concern) Explanation of Pain: Quality of Pain: (circle appropriate) Sharp - shooting / dull -achy Cause: Onset: Worse with: Better with: Have you seen a specialist? Lab tests / X-Ray / MRI /Scan (circle) Date: Medication you ve been given for this condition: Better / unchanged / worse (Circle one) 4
5 General (Check box or circle when applicable) Overall energy Good Fair Poor Time of day when lowest? Body temperature tend to run cold tend to run warm Cold hands Cold feet Sweats easily Night sweats Chills Fevers Increased Appetite Decreased appetite Weight Gain / Loss Food Cravings: Sweet Sour Salty Spicy Strong thirst Lack of thirst Preference: Cold Warm Hot Room Temp Eating disorder Sleep Good Fair Poor Difficulty Falling asleep Difficulty staying asleep Get up to go to bathroom (# ) Vivid Dreams Insomnia Sleep Apnea Clench Jaw / Grind teeth Head & Neck Concussion / Whiplash (date ) Dizziness / Fainting / light headed Neck stiffness Enlarged lymph nodes Poor Memory / difficulty concentrating Headaches / migraines Eyes Glasses / Contacts Redness / itching / tearing Floaters / spots cataracts / Glaucoma / Macular degeneration Floaters / spots Poor vision (near or Far) Blurred vision / Poor night vision Ears Infections recurring? Ringing (High pitched or Low pitched) Decreased Hearing Skin & Hair Rashes / Hives Acne / Pimples Dry skin / oily skin Bruise easily Eczema Psoriasis Shingles Herpes 1 or 2 Tumors, Lumps/ Cysts (Location ) Hair loss (sudden?) Nose, Throat & Mouth Nosebleeds Sinus Infections Hay Fever / Allergies Gum / Teeth problems Grinding teeth (Mouth guard?) Difficulty Swallowing Frequent Sore throats Dry Mouth or Throat Hoarse voice Respiratory Asthma / Bronchitis Frequent Colds COPD / Emphysema / Pneumonia Chronic cough (dry or productive) Coughing blood Cardiovascular High / Low Blood Pressure High cholesterol Phlebitis / vein inflammation Blood clots Palpitations Irregular Heart beat Chest Pain / Pressure (rest or exhertion) Poor circulation Swelling of hands / feet 5
6 Neurological Seizures Tremors (Location ) Numbness or tingling of limbs Pain Paralysis Gastro-intestinal Nausea Vomiting Indigestion Flatulence (gas) Belching Diarrhea (chronic or alternating) Constipation (chronic or alternating) Blood in stools Pale or black stools Rectal pain / hemorrhoids Pain or cramps IBS / Chron s / Ulcerative colitis Ulcers Bad Breath Gallbladder disorder Genito- Urinary Frequent urination Urgency Unable to Hold / incontinence Pain with urination Blood in urine Weak urine stream Kidney Stones UTI s Male Impotence Premature Ejaculation Testicular lumps / masses Benign Prostatic Hyperplasia Genital itching / pain Genital Lesions or discharge Weak Urinary Stream Decreased / Excessive Libido Female Urinary Tract Infections (UTI s) Vaginal or Yeast Infections Genital Pain or itching Genital Lesions or discharge Pelvic Inflammatory Disease (PID) Abnormal Pap Smear (date ) Irregular Periods Painful Periods / cramps PMS symptoms Abnormal bleeding Breast Lumps / pain Decreased or Excessive Libido Date of Last Period: Pregnancies Total Pregnancies Living Ectopic # Miscarriages # Abortions Age of onset of Menses Age of onset of Menopause Menopausal Syndrome - Date of Last Period: - Hormone replacement Therapy: Psychological Depression Anxiety / Stress Panic Attacks Irritability / Anger Addictions To what: Treated for Emotional / Psychological Issues For what: Medications: Infection Screening (Positive Test) HIV TB Hepatitis Gonorrhea Syphillis Genital Warts or HPV Herpes Oral or Genital 6
7 Patient Treatment Informed Consent Agreement Name Date of Birth I hereby give my consent for Anita Lang- Bakar, L.Ac with Driftwood Acupuncture & Wellness to perform treatment utilizing Traditional Chinese Medicine techniques. I understand that the techniques utilized in Chinese Medicine and by Driftwood Acupuncture & Wellness are not experimental, but backed by over 3 thousand years of clinical experience in China and used successfully in the West. These practices are accepted therapy recognized by the State of California. The methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui Na (Chinese Massage), Guasha (scraping technique), Chinese Herbal Medicine, and nutritional counseling. I understand that all acupuncture or other Traditional Chinese treatments will be performed by a CA State licensed acupuncturist. I understand that all needles utilized for the acupuncture treatments are pre- packaged, sterile, single- use needles that have never before been used and will be discarded after each treatment. Although the clinic uses sterile, disposable needles and maintains a clean and safe environment, infection is another possible risk of treatment. Risks associated with moxibustion treatment may include burns and/or scarring, although unusual and rare. I understand that while this document describes major risks of treatment, other unanticipated side effects may occur. I do not expect the acupuncturist to be able to anticipate all possible complications from treatment, but I do wish to rely on the acupuncturist to exercise judgment during the course of treatment, which based upon the facts known and my condition, is in my best interests. Initial Date The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that have been recommended are safe in the practice of Chinese Medicine, although some may be toxic if not taken as prescribed. Other possible side effects of herbal treatments are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I understand that some herbs may be inappropriate during pregnancy. I understand that the herbs need to be prepared and the tea consumed according to the instructions provided verbally and in writing. The herbs may have an unpleasant taste or smell. I will immediately notify my practitioner of any unpleasant effects associated with the consumption of herbal teas or products. I will notify Anita Lang- Bakar, L.Ac if I am or become pregnant. I will notify Anita Lang- Bakar, L.Ac if I change any of my Medications or start taking new ones. I agree to follow all treatments only as recommended/prescribed. If I am experiencing any side effects or difficulties I will notify practitioner as soon as possible. Initial Date 7
8 Privacy Policy I understand that the clinical and medical staff may review my files but all my records will be kept confidential and can only be released under my personal written consent or when required by law. Initial Date Cash and Personal Insurance Financial Agreement You are financially responsible for all services rendered to you in this office. Payment is made in full (100%) for each visit at the time of visit unless special arrangements have been made with your provider. Cancellation Policy No charge will be made for cancellations or appointment changes if 24 hours notice is given. For cancellations with less than 24 hours notice full price will be charged. Payments need to be made in full by you at the time of service. I hereby certify that I have read (or have had it read to me) and understand the above consent form. This consent form shall cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment. I may have a copy of this form for my records. Signature Date: (Patient/Representative) Clinician Date: (Anita Lang- Bakar, L.Ac.) 8
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