Patient Intake FormPatient Intake Form Contact Information Full Name Pronouns and Preferred Name Address Zip Code Email Mobile Phone Birth Date Age Occupation Have you been treated by acupuncture before? Yes No Referred by Physician Name May we contact them? Yes No Emergency Contact Phone Relationship Signature Date Basic Information Main Concerns (Include Duration) Have you been given a diagnosis? If so what? What kind of treatment have you tried? What alleviates your symptoms? Is there anyone in your family with the same/similar problems? Past Medical HistorySevere Illness Cancer Diabetes Hepatitis Thyroid Disease Seizures Fibromyalgia Arthritis Tuberculosis Hypertension Depression/Anxiety Heart Disease Anemia Digestive Disorders Breathing Problems HIV/AIDS Positive STD Other Other Family Medical History (Please write in family member) Cancer Diabetes Hepatitis Hypertension Heart Disease Stroke Asthma Alcoholism Miscarriage Other Patient Details Hospitalizations / Surgeries Significant Trauma (auto accidents, sports injuries, etc.) Allergies (drugs, foods, chemicals) Chemotherapy type and regimen (if applicable) Radiation regimen (if applicable) Occupational Stress (chemical, physical, psychological, etc.) Personal Height Weight HabitsDo you smoke? Yes No What? How much/day? Since Do you take recreational drugs? Yes No What? Do you exercise regularly? Yes No Please Describe How many hours do you sleep in general? When do you go to bed? Diet How much caffeine do you drink/day? (Include: coffee, tea, colas, etc.) Kind of alcohol you usually drink, if any? How much water do you drink per day? Are you a vegetarian? Yes NoDo you eat a lot of spicy food? Yes NoPlease describe your average daily diet (be as specific as possible): Morning Afternoon Evening Snacks Please check if you have or have had any of the following conditions within the past 6 months:General Poor sleeping Fatigue Fevers Chills Night sweats Sweat easily Tremors Cravings Poor appetite Change in appetite Poor balance Localized weakness Bleed or bruise easily Weight Loss Weight Gain Peculiar taste Desire hot food Desire cold food Strong thirst (cold or hot) Sudden energy drop Time of day (sudden energy drop) Skin & hair Rashes Ulcerations Hives Itching Eczema Acne Dandruff Dry Skin Recent Moles Loss of hair Purpura Change in hair or skin texture Other Other Musculoskeletal Joint disorders Weakness in muscles Pain/Soreness in muscles Tremors Difficulty walking Cold hands/feet Swelling of hands/feet Back Pain Spinal Curvature Hernia Numbness Tingling Paralysis Neck Tightness Shoulder pain Neck pain Hand/wrist pain Hip pain Knee pain Sprain of joint Other Other Head, Eyes, Ears, Nose, and Throat: Dizziness Concussions Migraines Glasses/lens Eye Strain Eye Pain Color Blindness Night Blindness Poor vision Cataracts Blurry vision Earaches Ringing in ears Poor hearing Spots in front of the eyes Sinus problems Nose bleeding Sore throat Grinding teeth Teeth problems Facial pain Jaw clicks Sores on lips/tongue Difficulty swallowing Other Other Cardiovascular High Blood Pressure Low Blood Pressure Chest pain Palpitation Fainting Phlebitis Irregular heartbeat Rapid heartbeat Varicose Veins Other Other Respiratory Cough Coughing blood Wheezing Difficulty in breathing Bronchitis Pneumonia Chest pain Production of phlegm Other Phlegm color (if applicable) Other Gastrointestinal Nausea Vomiting Diarrhea Constipation Gas Belching Black Stools Blood in stools Indigestion Bad breath Rectal Pain Hemorrhoid Abdominal cramps/pain Gallbladder problem Parasites Chronic laxative useBowel movements: Frequency Color Odor Texture/form Other Neuro-psychological Loss of Balance Lack of Coordination Concussion Depression Anxiety Stress Bad temper Bi-polar Other Other Genito-urinary Pain on urination Frequent urination Blood in urine Urgency to urinate Kidney Stones Unable to hold urine Dribbling Pause in flow Frequent urinary tract infection Pain in genital Itching of genital Other Other Female Frequent vaginal infections Pelvic infection Endometriosis Vaginal discharge Fibroids Ovarian cysts Irregular periods Clots Pain/cramps prior/during periods Breast tenderness Breast lumps Fertility Problems Moodiness related to periods Low libido Hot Flashes Vaginal dryness Other Other #of pregnancies #of births Miscarriages Terminated Premature births Male Prostate problems Impotence Frequent seminal emission Painful/swollen testicles Fertility problems Discharge Ejaculation problems Other Other Are there any areas that you protect? Any pain or tenderness? Any numbness or reduced sensation? Any areas that are warm or red? Any swelling or tendency to swell? Have you had any lymph nodes surgically removed? If Yes, where were they removed from? Do you have any SITES to be mindful of, due to (check boxes that apply) incision/wound radiation site neuropathy skin sensitivity/condition fracture history tumor site medical device area of infection Please describe Are you experiencing any of the following (check boxes that apply) history or risk of lymphedema recent surgery infection or fever area of pain swelling risk of easy bruising pain medication fragile bones fatigue fragile/sensitive skin nausea other Other Informed Consent Name I [named above], do hereby request and give permission to receive treatment from Sage Acupuncture LLC, and any affiliated Licensed Acupuncturist. Traditional Chinese Medical treatments include various modalities including but not limited to acupuncture, cupping, gua sha, herbal, and dietary supplements. I understand that I have the right to inquire about and refuse any part of the treatment.I understand and am informed that, as in allopathic medicine, in the practice of Traditional Chinese Medicine there are some risks of treatment. I understand that although these risks are unlikely to occur, they are possible. These risks include but are not limited to: bleeding, bruising, nerve damage, punctured organs, aggravation of symptoms, the appearance of new symptoms, fainting, and fatigue. I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise such judgment to be in my best interest based on the known facts at the time. Although I am aware that acupuncture and the other procedures used in Traditional Chinese Medicine have helped millions of people, I understand that no guarantee of cure or improvement in my condition is given or implied.Policies & Procedures:Appointment Reminders and Follow Up Communication We may use or disclose your health information to provide you with appointment reminders and follow up communication via phone, voicemail, email or letter.Privacy Practices I have reviewed Sage Acupuncture LLC’s notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.PaymentPayment is due at the time of service. We accept cash, checks, and most major credit cards.Your appointment time is reserved specifically for you. In the event of a missed appointment or an appointment canceled for any reason with less than 24 business hours notice you will be charged a fee.A $30 fee will be charged for returned checks.We reserve the right to change our fee scale without notice.Media Release Any photographs, audio or video recordings of myself or my family that I participate in or submit to Sage Acupuncture LLC, may be used for any purpose without compensation in perpetuity.I have completed this form to the best of my knowledge. I have read and understood the Informed Consent and Privacies & Procedures information. By signing below I agree to a course of treatment in Traditional Chinese Medicine and intend this consent form to cover the entire course of treatment for my present condition as well as any future condition(s) for which I seek treatment with this practice. Patient's Name Patient's Signature Date Other Medicines Medicine Reason for taking Dose Add Remove Submit If you are human, leave this field blank.