Acupuncture Intake Survey Kindly complete this form prior to your first acupuncture program session. Member InformationFirst Name(Required)Last Name(Required)Date of Birth(Required)Preferred Email Address(Required)1. Age(Required)18 to 2425 to 3435 to 4445 to 5455 to 6465 or over2. Gender(Required) Male Female Non-binary Transgender Other 3. Home Zip Code(Required)4. Work Zip Code(Required)Health Background5. Please select your chief complaints. Select all that apply.(Required) Chronic pain (e.g., back pain, neck pain) Stress or anxiety Insomnia or sleep disturbances Headaches or migraines Digestive issues (e.g., bloating, constipation) Fatigue or low energy Menstrual irregularities or menstrual pain Allergies or sinus issues Joint pain or arthritis Emotional imbalances (e.g., depression, irritability) None 6. Have you had any medical treatment for the above conditions?7. Please list all medications including supplements currently taking and for what reason8. I am currently taking an herbal supplement(Required) Yes No 8. If "Yes", please list the name(s) of the supplements:Dosage: For What Condition:9. Please list any food, medication, or other allergies.10. Medical history. Check all that apply. asthma autoimmune disease blood disorder/anemia cancer diabetes 1 diabetes 2 depression/mental illness physical abuse drug/alcohol abuse HIV/AIDS heart disease hepatitis C high blood pressure high cholesterol seizures/stroke tuberculosis appendix gallstones hypothyroid hyperthyroid meningitis PTSD Select All11. Other important health information. Check all that apply. blood thinners breast implants pacemaker or ICD gluteal implants implanted medical device other implants fainting episodes issues with needles Select All12. List history of hospitalizations, operations, and/or significant traumas.13. Family medical history. Check all that apply. addictions asthma cancer diabetes fatty liver high blood pressure heart disease mental disease stroke thyroid disease others Select All14. I have a Primary Care Physician.(Required) Yes No Lifestyle15. Are you currently “dieting” or following a dietary regimen?(Required) Yes No If you selected “Yes”, please list an example of your typical breakfast, lunch, and dinner meals.16. I do muscle strengthening exercises 2 or more times a week.(Required) Yes No Sometimes 17. I do moderate-intensity aerobic exercise at least 150 minutes (2 hr and 30 minutes) per week.(Required) Yes No Sometimes 18. Please select all that apply. Sleep after midnight Drink 1 cup of coffee per day Drink more than 1 cup of coffee per day Drink soda Drink 1-2 glasses of alcohol per night Drink alcohol on the weekends Smoke/vape tobacco Smoke/vape marijuana Select All19. Please rate your current stress level with 0 being “Calm” and 10 being “Extremely stressed”.(Required)01234567891020. On a scale of 0 to 10, please rate your confidence in managing your stress, from 0 being “Not at all confident” to “Extremely confident.”(Required)01234567891021. On a scale of 0 to 10, how well do you understand the ways in which acupuncture supports your overall wellness, with 0 being "Not at all" and 10 being "Extremely well"?(Required)012345678910Musculoskeletal22. What areas are painful? Check all that apply. head neck shoulder upper back middle back lower back ribs wrist hip upper leg side of leg lower leg knee ankle foot fingers toes groin general muscle weakness muscle tightness full body aches/pain jaw repetitive injuries Select All23. For any painful areas selected above (Question 22), when did the symptoms start?24. What makes it feel better? (Select all that apply) Activity Rest Stretching Heat Cold Massage Other 25. What best describes the pain? (Select all that apply) Sharp Shooting Dull ache Burning Numb tingling Massage Other 26. How much has the pain interfered with your normal work? Not at all A little bit Moderately Quite a bit Extremely 27. How much has the pain interfered with your social activities? Not at all A little bit Moderately Quite a bit Extremely 28. Does this pain impair your daily activities? Yes No Sometimes 29. Please rate your pain on a scale from 0 to 10 with 0 being “No pain” and 10 being “I need to go the ER”012345678910Energy30. Select all that apply. general tiredness lack of morning energy weakness of limbs spontaneous sweating poor appetite bearing-down sensation in the abdomen fatigue foggy head shortness of breath frequent sighing a feeling of having a lump in the throat Select AllSleep31. Select all that apply. I have no sleep issues difficulty falling asleep difficulty staying asleep vivid dreams low energy in the morning nighttime urination history of insomnia daytime drowsiness sleep apnea snoring Select AllBody Temp/Sweat32. Select all that apply. I generally feel hot I generally feel cold I have a hot body and cold limbs prefer hot drinks prefer cold drinks hot palms/feet dry skin lack of sweating excessive sweating spontaneous sweating foul-smelling sweat hot flashes Select AllResipiratory33. Select all that apply. shortness of breath asthma dry cough wet cough sinus infections environmental allergies a diminished sense of smell skin problems spitting phlegm nose bleeds rattling sound with voice dry skin Select AllCardiovascular34. Select all that apply. palpitations high blood pressure low blood pressure dizziness easily startled shortness of breath on exertion stuffiness in chest chest pain chest tightness stabbing chest pain swollen ankles left arm pain Select AllGastrointestinal/Hepatic35. Select all that apply. constipation diarrhea borborygmus (gargling stomach) loose stool undigested stool blood in stool hemorrhoids vomiting heartburn nausea hiatus hernia craving sweet food edema (swelling ankles) over-thinking food allergies excessive hunger lack of appetite feeling full/heaviness bad breath gallstones removed upper abdominal pain difficulty digesting greasy foods abdominal/rib side discomfort rectal pain anal fissures Select AllGenitourinary/Reproductive36. Select all that apply. urinary frequency difficulty urinating waking to urinate blood in urine painful urination kidney stones frequent UTI's dribbling after urination decrease stream power enlarged prostate low semen volume premature ejaculation decreased libido impotence high libido genital itching genital sores/STD Select AllHead, Ears, Eyes, Nose, Throat37. Select all that apply. mouth ulcers decreased vision floaters in vision blurry vision eye pain dry eyes headaches migraines concussions night blindness facial pain tinnitus (ringing in ears) poor hearing nose bleeds nasal drainage glasses/contact lenses tonsils removed tongue ulcers Select AllMental Health38. Select all that apply. irritability outbursts of anger stress timidity anxiety history of a panic attack dream disturbed sleep mental restlessness depression racing thoughts poor memory other Select AllWomen's Health39. Select all that apply. no menstrual cycle irregular periods extended menstrual cycle (greater than 32 days) shortened menstrual cycle (less than 24 days) mid-cycle bleed prolonged period (greater than 5 days) a short period (less than 3 days) pain and cramping during periods light blood flow heavy blood flow breast pain before/during a period irritable or depressed before/during a period PMS color of menses bright red color of menses wine red color of menses dark menstrual clots PCOS uterine fibroids endometriosis ovarian cysts PID frequent yeast infections vaginal discharge vaginal dryness breast lumps currently pregnant trying to get pregnant infertility previous live birth vaginal deliveries caesareans premature births history of miscarriage previous abortions IVF IUI Select All40. I have had IUI(Required) Yes No Number of rounds41. I have had IUD(Required) Yes No Number of roundsHow many mature eggs?How many embryos?42. I have experienced a miscarriage(Required) Yes No At what week?Please list any medications used43. Please note any other health information you would like to share.Informed Consent and Privacy Practices for Acupuncture Services(Required) By checking this box, I hereby consent to the following:I certify that the above health information is correct to my knowledge. The information provided in this form contains protected health information (PHI), which is safeguarded under federal and state privacy laws. Your PHI will be kept confidential and used solely for authorized purposes. We will share your PHI electronically using encryption and access controls to safeguard it during transmission and storage. Your PHI will be maintained in compliance with applicable federal and California privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA) and the California Confidentiality of Medical Information Act (CMIA). I hereby request and consent to acupuncture treatment. I understand that results are not guaranteed, and I have the right to refuse or discontinue any treatment at any time and understand that this refusal may affect the expected results. I agree to inform the acupuncturist of any changes in my health condition or medications prior to each treatment session. I understand that acupuncture is generally safe and effective. However, I understand that there are risks involved with my consent to acupuncture treatment including side effects such as dizziness, fainting, bruising, numbness and/or tingling near the needling sites that may last a few days. I understand that though unusual, additional risks of acupuncture include spontaneous miscarriage, nerve damage, and/or organ puncture, including lung puncture (pneumothorax). I understand that although the acupuncturist(s) use sterile disposable needles and always maintain a clean and safe environment, infection is another possible risk. 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 judgement during treatment. I understand that if I experience any adverse reaction during or after treatment, I should promptly inform the acupuncturist and/or seek emergency medical attention if appropriate. I hereby request and consent to the performance of acupuncture treatments (or on the patient named below, for whom I am legally responsible) by the acupuncturist(s) administering treatment at any time. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to acupuncture treatment and have been told about the risks. I intend this consent form to cover all acupuncture treatments at any time. I understand this includes the entire course of treatment for my present condition and any future condition(s) for which I seek treatment.Signature(Required)Today's Date(Required) MM slash DD slash YYYY
