INTAKE WOMEN — Courtland Acupuncture

GENERAL INFORMATION

Address

Marital Status

Email

Emergency Contact: Phone #, Name, Relationship to Patient

Family Doctor: Name, City, Phone #

Main Occupation(s)

How did you hear about us?

Have you had Acupuncture before. If yes, with whom?

Have you had Shiatsu massage before. If yes, with whom?

Thank you for filling the form below. It will help us understand better what your health issues are about, applying the hoslistic approach of Acupuncture and Traditional Chinese Medicine

CURRENT HEALTH CONCERNS

Main Issue you would like help with (Chief Complaint):

When did it start? What caused it?

Indicate the level of pain if any (0 = no pain, 10 = worse pain you've had). Describe what you feel. What makes it better, what makes it worse? Did you get a diagnosis, are your receiving treatments, which ones? How does it affect your life? What have you done to help it so far?

Other concerns you would like help with?

MEDICAL HISTORY

Other diagnosis:

INJURIES, SURGERIES, HOSPITALIZATIONS: please list with dates

MEDICATIONS: please list current prescriptions and what they are for

SUPPLEMENTS AND NATURAL REMEDIES: please list

How was your health when you were a child / teen? Birth trauma, prone to illnesses, lots of antibiotics, stressful / dysfunctional home, allergies, traumas etc?

Family Health History (Father, Mother, Other)

HEALTH AND LIFESTYLE

Weight and height

Work Hours Per Week

Number of days of vacation each year

Sleep Hours Per Night

Exercise Type and Frequency

Special Diet or Food Sensitivity

Caffeine/Smoke/Alcohol/Substance Use & Frequency

What do you typically have for breakfast?

What do you typically have for lunch?

What do you typically have for dinner?

What snacks do you typically have, and when?

WOMEN'S HEALTH

Age first menstruation?

Age of menopause (if applicable)

Number of children

Number of miscarriages, abortions?

Length of cycle, ie Number of days between day #1 of a period and day #1 of the next period (eg. 28 to 30)

Number of days each period lasts (eg. 5)

Other information regarding women's health?

MUSCULO-SKELETAL / BODY OVERVIEW

Please list the scars you have (where, why)

Other:

HEALTH INDICATORS

Other

Allergies, others:

Other

Would you like to add anything else?