ࡱ> egd jbjbj v(@  YYY4DlY.=====$)EYv"  ==9 8=Y=A=0/)0Y0LY|LY :  Kristin Wisgirda, Licensed Acupuncturist, Master of Traditional Oriental Medicine 130 Liberty St., unit 13B, Brockton, MA 02301 508-427-6575 The following is considered privileged information. Your answers are absolutely confidential. Name:_____________________________________Date of Birth:______________Date:___________ Your preferred contact number: ______________________________ (home/mobile/work) Alternate contact number: ___________________________________(home/mobile/work) Home Address:___________________________________________________________________________ Email:__________________________________________ Do you need appointment reminders? YES/NO If yes, how would you like to be contacted: phone/email/text, at this number___________________________  Occupation:___________________Emergency Contact:____________________Phone:_________________ Have you had acupuncture before?_____ Have you been treated by a Chinese herbalist before?_______ Current Medications: (any prescriptions, vitamins, herbs and other medications that you take regularly) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Allergies:(include drugs, foods, latex, animals,etc)_________________________________________________ __________________________________________________________________________________________ Hospitalizations/Surgeries:(include the year and the diagnosis or operation)____________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please circle any conditions your have experienced, past or present: High Cholesterol Heart problems Stroke High blood pressure Seizures Diabetes Hepatitis/jaundice HIV/AIDS Concussion Mononucleosis Eczema Eating Disorder Asthma Thyroid disorder Appendicitis Tuberculosis Gallstones Pneumonia Autoimmune disease Prolonged or frequent use of antibiotics or steroidal drugs (eg Prednisone) Cancer: __________________________________________Addictions:______________________________ How often do you use the following substances? coffee_______black/green tea __________ nicotine________ alcohol_____sugar in any form________ soft/energy drinks______ non-medical drugs_______ artificial sweeteners What kinds of physical exercise do you do and how often do you do them?______________________________ _________________________________________________________________________________________ ________________________________________________________________________________________ Describe your chief complaint: When did this develop? How did this develop? Does anything make it better or worse? Consider time of day, position, heat or cold, stress, emotions, kinds of medical care, menstrual cycle, adequate rest, lack of sleep, certain foods, eating, not eating, damp or rainy weather, exercise or stretching. Better:____________________________________________________________________________________ Worse:____________________________________________________________________________________ Please take the time to fill out the following. The information that you provide will allow me to formulate a complete health profile for you. Circle the symptoms that you experience currently or have experienced frequently in the last year. General m frequent colds m warmer than other people/hot hands or feet m cooler than other people/cold hands or feet m hotflashes m fevers m muscle weakness or easy fatigue m seizures m lack of coordination m loss of balance m tremors m tics m sweats easily m rarely sweats m always thirsty m never thirsty m I can t gain weight. m I can t loose weight. m Swelling m in hands m in face m ankles or legs m tends to overreact m tends to hold in emotions m has difficulty relaxing m mentally restless m fuzzy headed/unclear thinking m low motivation m highly motivated m obsessive thinking m poor memory m anxiety/panic attacks m depression m sadness m worry m seasonal affective disorder m irritability m frequent anger m easily stressed m emotionally changeable m attention deficit disorder m uncontrolled crying Chest m chest pain m chest tightness m hard time breathing deeply m palpitations/heart racing m cough or wheezing m recurrent bronchitis/pneumonia Sleep m Wakes during the night m to urinate: __ times m for no reason m because of dreams m physically restless m mentally restless m with heart racing/palpitations m in a fright m feels unrested in the morning m hard to fall asleep m snores m nightmares m night terrors m nightsweats Number of hours of sleep a night: ___ Head and Neck m history of concussion m headaches m migraines m tension m sinus headaches m dizziness/vertigo m poor vision m spots/floaters in vision m poor night vision m eye pain m eye itching m face pain m jaw pain m tmj m facial twitches m sinus congestion m blows nose in morning m recurrent sinus infections m runny nose m earaches m loss of hearing m ringing in ears m recurrent ear infections m recurrent sore throats m hoarseness m difficulty swallowing m lump in throat m phlegm in throat m hayfever/allergies Skin/surface m dry skin m excessively oily skin m psoriasis m eczema m red, inflamed skin m slow to heal sores m acne m hives m varicose veins m abnormal hair loss m swollen glands m brittle/soft/peeling nails Digestion m restricted diet: explain_______________________________ __________________________________________________ m poor appetite m eats at irregular times m emotional/stress related overeating m eats sweets often m indigestion m often feels bloated m stomach ache m nausea m vomiting m frequent gas m burping m acid reflux/GERD m mouth sores m irritable bowel syndrome (IBS) m bowel movements m how many a day___ m skips one or more days m have a hard time or pain passing m urgent m loose m watery m contains undigested food m foul odor m contains mucus m contains blood m light, tan or white colored m black and tarry m dry, hard stools m pencil thin stools m rabbit/pellet stools m alternating loose stools and constipation m ungratifying/partial defecation m need laxatives, coffee, or other assistance to have a bowel movement Urination m infrequent urination m frequent urination m urgent urination m incomplete urination m loss of urine control m dark urine m discomfort with urination m scanty urine m profuse urine Musculoskeletal m weakness in lower back, hips, knees, ankles or feet Pain, weakness, or numbness in m upper back m middle back m lower back o $ 3 8 D c d  5 N m p   ' 8 ? G Y 7=KXYþh_=vh R|6>* h_=v6'jh_=vh, 6UmHnHtHu h, 6 h,F6h R|h R|6 h R|6h R|h_=vh R|>* h R|>*h R|h R|>*hth R|CJaJhtCJaJh R|h R|CJaJ hre 66TD     e / Yxy@gd R|gd,F$a$gd R|$a$gdt$a$gd R|$a$gdre Yu(+aeln *6xyBV@np|/x!h R|h6A6hth R|6>*h R|ht6 h6A6 ht6htht6>*h R|h_=v6 h R|6 h_=v6h R|h R|6h_=vh R|6>*D@p04   @ gdS[8$a$gdk(gdtgd R|!34:sBPz   "Br Z\np"&JLɾ}u}m}}}hN_CJaJhM>CJaJh2CJaJhhv CJaJh*KCJaJh&CJaJhHCJaJhS[8CJaJhk(hk(5>*CJaJhk(hS[8CJaJhk(ht6 h(:6 hS[86 h 6hre hre 6 hk(6 h R|6h R|h R|6 ht6)\p8V"$L8\gd2gdS[8^Zz.0< H J P \ !!!D!F!N!r!t!!n"p"r""yqqqhCJaJhh*KCJaJhDCJaJh*KCJaJh*K5>*CJaJh&5>*CJaJh&hvECJaJhvE5>*CJaJhvECJaJhHCJaJh>oCJaJh2CJaJh&CJaJhk(CJaJhN_CJaJh(:CJaJ,>Zz.0<Tv J L N P \ !F!t!!gdDgdvEgdS[8!!"H"X"p"""""#@#V#r#####&$L$`$z$$$$$$"%Z%gd*KgdD"""##@#B#\#^#x#z######J$z$|$$$$$$"%$%Z%\%r%t%%%%%&&&&& 'F(|(~(((((պuhDhD5>*CJaJhhHCJaJhH5>*CJaJh(5>*CJaJhvE5>*CJaJhHhHCJaJhHCJaJh(:CJaJhh2CJaJh2CJaJh CJaJh 5>*CJaJhDCJaJhN_CJaJ.Z%r%%%%%.&F&t&&&&&&&&&&&&& ' 'N'd't'''''gd*K''&(F(~((()l)))*,*F*p******++\+~+++0,H,^,v,gd*K()D)j)l)n)))),*.*p****+\+,,,6-8-.*.b..../ /F/H/V/h/j/r/z/|////0ººººª{phH5>*CJaJh5_h5_5>*CJaJhL5>*CJaJh(5>*CJaJhvE5>*CJaJhS[8CJaJhHCJaJhvECJaJh CJaJh5_CJaJh hD5>*CJaJhN_CJaJh*KCJaJh2CJaJhLCJaJ)v,,,,"-d----.|..J/h/j/l/n/p/r/t/v/x/z/|////0gdS[8gdLgdN_gdvE040b0z00000 1v1x11112 R"R.R>RJRXRhRtRRRRRRRRgdS[8000 1 1v1x12RRRT*CJaJh@"CJaJUhLCJaJhM>CJaJh5_5>*CJaJhM>5>*CJaJh5_h5_CJaJh5_h5_>*CJaJ1m neck m shoulders m arms m elbows m hips m knees m ankles m feet m all joints m legs Men Only m genital pain m groin pain m impotence m sexual dysfunction m discharge from penis m varicocele/hydrocele m prostate problems m low sperm count m low sperm motility m poor sperm morphology Women Only Age at which menses began________ Date last period began_____________ Date prior period began____________ Normal number of days (not on medication) between the start of one period and the start of the next_________ Number of days of flow_________ Any recent changes in your normal pattern?_______________ Amount of flow______________________ Color of flow m pink m red m dark red m purple m brown m black Any clots?________ Size/color of clots__________________ Any cramps?____When, where and how intense?__________ Any premenstrual symptoms?__________________________ __________________________________________________ When do they start?___________________________ Do you bleed or spot between periods? If so, when?________ __________________________________________________ Do you have any symptoms, such as breast tenderness, bloating, headaches, or abdominal pain, around midcycle or ovulation?_________________________________________ __________________________________________________ Have you taken medication to help you ovulate?___________ Vaginal itching?________ Vaginal sores?_______________ Vaginal dryness?_____ Describe any vaginal discharge that you have through the month:____________________________________________ __________________________________________________ Do you get yeast infections regularly?_________ Do you have a history of sexually transmitted disease?______ If so, please describe:_________________________ Do you douche ?____Do you use vaginal lubricants?_______ Date of last PAP smear_____________ Have you ever had an abnormal PAP smear?______________ Have you ever had a cervical biopsy, cauterization or conization, or other procedure on your cervix?_____________ Have you been diagnosed with uterine fibroids or polyps?____ Have you been diagnosed with endometriosis?_____________ Have you been diagnosed with pelvic adhesions?___________ Have you been diagnosed with any pelvic abnormalities?____ Have you had any tubal operations?_____________________ Current birth control method:__________________________ Have you ever used an IUD?___________________________ Have you ever been on the birth control pill?______________ Have you ever used Depoprovera?______________________ Are you trying to get pregnant?_________________________ Do you have excess facial or chest hair?__________________ Do you have excessively oily skin?______________________ Do you have breast tenderness?_______ Lumps?___________ Have you noticed discharge from your nipples?____________ 24 hour cancellation policy: You are responsible for missed appointments with less than 24 hours cancellation notice and will be charged. 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