Initial Consultation Form - Rising Phoenix Acupuncture

Acupuncture Initial Consultation Form

Please complete this questionnaire carefully and thoroughly. The information you provide will assist me in creating a complete health profile for you. All of your answers are confidential. If you have any questions, please ask.

Date (optional) Your name Date of Birth (optional) Age Address City State Zip Phone Your email Emergency Contact Relationship Primary Physician Primary Physician phone How did you hear of Rising Phoenix Acupuncture? Occupation Gender Height Weight Do you have any allergies? Please specify. (Food, Environmental, Essential Oils, Medicine) Have you ever had acupuncture before? If so, was it for a particular issue What is your primary reason(s) for treatment today? Have you consulted a medical doctor for this condition? If so, what was the diagnosis? Are you currently receiving any treatments for this condition? If yes, please describe them: Please list any medications (prescription & over the counter), vitamins, supplements, herbs or homeopathic remedies you are taking, including dosage Have you had or recently been exposed to COVID-19 or similar virus? If yes, list time frame since exposure How much do you consume of the following per day (Water, Coffee, Tea, Soda, Alcohol, Cigarettes/other tobacco products) Do you prefer (warm drink, cold drinks, room temperature drinks) What are your typical eating habits? (Skip meals, Eat too fast, Eat when not hungry, Excess hunger, No desire to eat, Cannot eat when stressed or worried, Vegetarian, Vegan, Craving specific foods) What are your typical sleeping habits? Hours slept at night (Fall asleep quickly, Trouble falling asleep, Trouble staying asleep, Deep Sleeper, Light Sleeper, Frequent dreaming, Disturbing dreams, Difficulty waking up, Frequently wake up at the same time during the night) How would you describe your energy levels? (High, all day long, varies, Low, all day long, varies, Normal/Consistent, Chronic Fatigue) Do you have an aversion/dislike to any of the following? (Cold, Wind, Dampness, Heat, Loud noises) What does your average body temperature feel like? (Hot, Cold, Hot at night, Cold at night, Cold hands & feet, Night Sweats, Sweat Easily, Sweating Difficult, Other Hot areas of the body/What areas) Cardiovascular (Pacemaker/date, Heart Disease, Blood Pressure, High Blood Preassure, Low, Chest Pain, Palpitations, Clots, Stroke, Varicose Veins, Edema, Poor Circulation, High Cholesterol) Energy & Immunity (Chronic Fatigue Syndrome, General Fatigue, Slow Wound Healing, Bruise easily, Chronic Infections, Frequent Allergies) Neurological/Emotional (Vertigo, Dizziness, Loss of balance, Numbness, Tingling, Paralysis, Seizures, Epilepsy, Dyslexia, ADD, ADHD, Anxiety, Panic Attacks, Mood Swings, Depression Mild, Clinical Depression, Parkinson’s, Poor Memory, Anorexia, Bulimia, Alzheimer’s, Dementia or Other) Respiratory (Asthma, Emphysema, Pnuemonia, COPD, Bronchitis, Frequent Colds, Cough w/phlegm, Cough w/blood, Chest Heavy, Chest Tight, Tuberculosis or Other) Genito-Urinary (Kidney Disease, Kidney Stones, Incontinence, Urination Frequent, Urination Painful, Urination Incomplete, Urine Dark, Urine Light, Urine Bloody or Other) Gastrointestinal-Abdominal (Heartburn, Acid Reflux, Gas, Nausea, Vomiting, Ulcer, Bloating, Hermorrhoids, Gall Bladder Disease, Gall Stones, Hernia, Liver Disorder, Constipation, Diarrhea) How many Bowel Movements Per Day? (Stool Normal, Stool Bloody, Stool Dry, Pain before bowel movement, during bowel movement, after bowel movement or Other) Head/Ear/Eye/Nose/Throat (Glasses, Contacts, Cataracts, Glaucoma, Impaired Vision, Dry Eyes, Tearing Eyes, Impaired Hearing, Ear Infections, High Pitch Ear Ringing, Low Pitch Ear Ringing, Ear Aches, Hearing Aids, Sinus Issues, Nose Bleeds/Frequency, Dry Nose, Dry Mouth, Teeth Grinding, TMJ, Bleeding Gums, Frequent Sore Throat, Swollen Glands) Skin/Hair (Acne, Hives/Rashes Where, Dermatitis, Eczema, Psoriasis, Shingles, Hair loss/thinning, Sensitive Skin, Fungal infection/Location/Frequency or Other) Musculo-Skeletal: (Neck Pain, Shoulder Pain, Muscle Spasms, Cramps, Osteoporosis, Joint Pain, Arthritis Type, Leg Pain, Low Back Pain, Middle Back Pain, Upper Back Pain, Broken Bones What Bones, Other) Endocrine (Thyroid Hyper, Thyroid Hypo, Hypoglycemia, Diabetes, Other) Other (Fibromyalgia, Lupus, Lyme Disease, Hepatitis A B C(Specify), HIV, Herpes Cold Sores, Hemophilia, Substance Abuse Type, Other) Men (Impotence, Prostrate Issues, Low Libido, High Libido, Painful Intercourse, ED, Vasectomy/Date, Other) Women (Are you pregnant? No, Possibly, Yes/How far along? Menopause? Low sex drive?) Any comments or notes regarding any issue not covered on this form Subject Signature