Reese Wellness
Acupuncture and TCM
针灸与中医
Reese Wellness
Acupuncture and TCM
针灸与中医

Empowering individuals in achieving their optimum Health
Client Health Survey
Client Health Survey
Reese Wellness Initial Intake
Personal Information
Name:_______________________________________
Age:_________ Birth Date:________________
Address: City, State, ZipCode:__________________________________________________
Cell Phone number:________________________
Alternate phone number: ______________________ Email:_______________________________________________
If under 18, person responsible for your account:____________________________________________
Gender: □ Male □ Female Height:____________ Weight:____________ Ideal Weight:_____________
Occupation:________________________________________________
Relationship status: □ Single □ Partnered □ Married □ Divorced □ Separated □ Widowed
Emergency Contact Name:________________________
Contact Phone:_________________________
Primary Care Physician:___________________________________ Phone:_______________________
May we contact him/her? □ Yes □ No How did you hear about us? _____________________________
Have you had acupuncture therapy before? □ Yes □ No
Are you a veteran? □ Yes □ No
Please indicate if any of the following pertain to you:
Hepatitis □ HIV □ High Blood Pressure □ Seizures □ Pacemaker □ Blood-Thinning Medication
Please indicate how much you consume of the following and how frequently:
Coffee:__________________ Soda:___________________ Water:_____________________
Alcohol:_________________ Tobacco:________________ Other drugs: _______________
Please list any prescription or over-the-counter medications, vitamins, and supplements you are presently taking and the reason for taking them:
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What would you like to accomplish with acupuncture? This is NOT your chief complaint but rather your health goal (i.e. to run a 5k without pain, to fly on a plane without dizziness, to have the energy to keep up with your nephew, etc.)
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Health History
Please indicate your top three health concerns for which you are seeking treatment and how long you have been experiencing them:
1.____________________________________________________________________________ 2.____________________________________________________________________________ 3.____________________________________________________________________________
What other forms of treatment have you sought? ______________________________________________________________________________
Does anything make your condition better or worse? ______________________________________________________________________________
Please list any surgeries or major health incidents (injuries, trauma, accidents, etc.) in your life and the date of occurrence:
______________________________________________________________________________
If you experience any physical pain, please indicate where and since when:
How would you characterize your physical pain?
□ dull/achy □ sharp/stabbing □ burning □ tingling /numbness □ electrical □ throbbing □ stiff □ tight □ continuous □ comes and goes □ fixed location □ moves around □ shooting/radiating
How would you rank your pain on a scale of 1-10, 10 meaning “I need to go to the Emergency Room.” Day to day: ___________
At its lowest: ___________ At its highest: ___________
Symptoms Survey
Please indicate the symptoms or conditions you currently experience at least a few times per month (circle which apply):
Digestive SP/ST:
Excessive appetite
Lack of appetite
Low energy after a meal Gas or bloating Acid reflux / heart burn
Other digestive issues Fatigue
Hemorrhoids Prolapse
Worried thoughts
Cardio and Mind HT/SI Difficulty focusing:
Poor memory Nightmares
Mentally restless Chest pain Palpitations Agitation / Fidgeting
Epigastrium and Blood LV/GB Vision issues
Dizziness
Ringing in the ears
Belching
Irritability
Depression
Brittle hair or nails Discomfort around rib cage Gallstones
Headaches
Lungs and Face LU/LI Cough:
Shortness of breath Congestion
Allergies
Tightness in the chest Spontaneous sweating Skin issues
Essence and Urinary KD/UB Kidney stones:
Hearing issues
Dry mouth
Low libido
Heat / sweating at nigh
Hot flashes
High libido
Edema / swelling
Urinary problems
Restless leg
Leg cramps
I usually feel: □ Hot □ Cold
Are any parts of your body hotter or colder than others? ________________
Have you experienced any form of trauma or abuse? _________________________________________________
Lifestyle:
How many hours of sleep do you get each night? ____________________________________________
Do you have difficulty with: □ Falling asleep □ Staying asleep □ Vivid dreams □ Waking not rested
□ Interrupted sleep:
When and why do you wake up? ________________________________________
How many bowel movements do you have in a day or week? __________________________________
Are your bowel movements: □ Well-formed □ Loose □ Small pebbles □ Easy to pass □ Difficult to pass
How would you rate your energy level on a scale of 1-10, with 10 being the highest:________________
How would you rate your stress level on a scale of 1-10, with 10 being the highest:_________________
Please list your primary sources of stress: __________________________________________________
How many hours do you work per week? ________ Do you like your work? ______________________
For Men:
Date of your last prostate exam:__________________ Are you currently sexually active? □ Yes □ No
Please explain any concerns you may have with your sexual function or libido: ______________________________________________________________________________ ______
Please list any STDs you have: __________________________________________________________
For Women:
Number of pregnancies:_________ Miscarriages:__________ Abortions:____________ Are you currently sexually active? □ Yes □ No
Age of first period:_______ Date of last period:___________ Number of days between periods:_______ Number of days of flow:___________ Color of blood:________________________________________
Please indicate if you experience the any of these symptoms before or during your menses: □ Lower back pain □ Diarrhea □ Constipation □ Moodiness □ Breast pain / soreness □ Blood clots
□ Increased appetite □ Decreased appetite □ Headache □ Nausea □ Insomnia □ Fatigue □ Heaviness
□ Bloating □ Cramping, please describe timing and severity: ___________________________________
Please indicate if you experience any of these other gynecological symptoms:
□ Vaginal dryness □ Profuse vaginal discharge □ Yeast infections □ Urinary tract infections
Please indicate if you have been diagnosed with any of the following:
□ Fibroids □ Fibrocystic breasts □ Endometriosis □ Ovarian Cysts □ Polycystic Ovary Syndrome □ Pelvic Inflammatory Disorder □ Infertility disorder: ________________________________________
Please list any STDs you have: __________________________________________________________
Is there any chance you might be pregnant now? ________________
Did we miss anything? Anything else you’d like us to know?
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CANCELLATION POLICY
Reese Wellness
We understand that there are times when a patient must miss an appointment due to emergencies or obligations with work or family. However, when a patient does not cancel an appointment in advance they are preventing another patient from utilizing that time. To ensure that our schedule remains accurate so that we may help as many patients as possible, appointments must be canceled at least 24 hours in advance. You will be charged $20 for a missed follow-up or $35 for a missed new patient appointment at your following appointment if you fail to give adequate notice.
Patient signature:_________________________________________________ Date:________________
If you are signing on behalf of someone else, please indicate your relationship to the patient next to your signatures. If you are signing on behalf of a minor, you must be his or her legal guardian.
INFORMED CONSENT TO TREAT
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by licensed acupuncturists within Reese Wellness, who now or in the future treat me while employed by, working or associated with or serving as back-up for the clinic, including those working at the clinic at which I am signing this form or any other office or clinic, whether signatories to this form or not.
I understand that methods of treatment may include, but are not limited to, acupuncture, acupressure/Tui Na, Chinese herbal medicine, nutritional supplementation, micro-current, and nutritional counseling.
I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. I understand that while this document describes the major risks of treatment, other side effects and risks may occur.
I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known is in my best interest. I understand that results are not guaranteed.
I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.
By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
PATIENT SIGNATURE _____________________________________________________________________ Date______________
HIPAA ACKNOWLEDGEMENT
I acknowledge that Reese Wellness has provided me with a Notice of Privacy Practices, and I agree to the terms indicated in them. By signing below, I also give my permission to be contacted by phone, email, or mail and that messages regarding appointments may be left for me on my voicemail.
PATIENT SIGNATURE _____________________________________________________________________ Date______________
If you are signing on behalf of someone else, please indicate your relationship to the patient next to your signatures. If you are signing on behalf of a minor, you must be his or her legal guardian.