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​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.)

______________________________________________________________________________

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.

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