Patient Intake Form

Garden Acupuncture, PC
790A Union Street
Brooklyn, NY 11215
GardenAcu.com

Welcome to Garden Acupuncture

Please take a moment to provide us with some information about yourself and your health conditions so that we may do our best to treat you.
Garden Acupuncture considers this information privileged physician/patient communication and will hold it in confidence.

Today's Date:
Full Name:
Date of Birth:
Age:
Sex:	Male Female
SSN:
Marital Status:	Single Married Separated Divorced Widowed
Address:
City:
State:
Zip Code:
Phone Number:
Cell Number:
E-mail:
Occupation:
Business Address:
Business City:
Business State:
Business Zip Code:
Business Phone Number:
How did you hear about Garden Acupuncture:
Have you previously been treated with Acupunture or Oriental Medicine:	Yes No

Emergency Contact Information
Name:
Relationship:
Phone Number:

Chief Complaint/Major Health Concern:
How did this condition develop:
How long has this condition persisted:
Is there anything that makes it better:
Is there anything that makes it worse:
Have you ever been treated for this condition:	Yes No
If yes, when:
where:
by whom:
What was the diagnosis:
What kind of treatment(s):
What were the results of the treatment(s):

Family Medical History
Maternal Side:
Paternal Side:
Siblings:

Birth History (prolonged labor, forceps, etc.):
Childhood Health:
Geographic location of upbringing:
Current emotional health:
Current quality of life:
Current relationship quality:
Current predominant emotion:
Recently, have you had any unusual stress:
Stress level:
Favorite time of year:
Least favorite time of year:
Hobbies/Recreational habits:
Do you have a regular exercise program:	Yes No
If yes, describe:
Traveled abroad in the past year:	Yes No
If yes, where:
Do you use coffee/tea, tobacco, or alcohol:	Yes No
If yes, how much of each and for how long:

Please list any substances that you are allergic to:
Medications, herbs, vitamins, and supplements that you are currently taking:
Please list any major surgeries you have had & date:
Please list any significant traumas (auto accidents, falls, etc.):
Do you have, or have you ever had any infectious disease:	Yes No
If yes, please describe:

Please check all significant illnesses that apply:	Arthritis Asthma Autoimmune Disease HIV/AIDS Cancer Connective Tissue D/O Diabetes Gallstones Heart Disease Hepatitis Hypertension Kidney Stones Rheumatic Fever Ruptured Appendix Seizure Thyroid Disease Venereal Disease
Please check any symptoms you currently have or have experienced in the past 3 months.
General Symptoms:	Chills Fever Allergies Aversion to Heat Aversion to Cold Fatigue Low Energy Dizziness Excess Thirst Lack of Thirst Insomnia Nervousness Numbness Spontaneous Sweating Night Sweating Lack of Sweating Weight Loss Weight Gain Peculiar Smells Sudden Energy Drops - If yes, when
Head, Ear, Eyes, Nose & Throat Symptoms:	Headaches Heaviness of Head Sore Lips Taste Changes Teeth Problems Earaches Hearing Loss Ringing in Ears Ear Discharge Sinus Problem Blurred Vision Double Vision Tunnel Vision Eye Pain Red/Inflamed Eye Cataract Nasal Obstruction Nasal Discharge Nosebleeds Loss of Sense of Smell Phlegm in Throat Hoarseness Recurrent Sore Throat
Respiratory Symptoms:	Asthma Shortness of Breath Emphysema Hay Fever Persistent Cough Coughing Blood Phlegm Production Recurrent Bronchitis Difficulty Inhaling Difficulty Exhaling
Cardiovascular Symptoms:	Chest Pain High Blood Pressure Low Blood Pressure Irregular Heart Beat Poor Circulation Varicose Veins Swelling of Ankles Hypochondriac Pain Distention in Chest/Hypochondrium
Gastrointestinal Symptoms:	Abdominal Pain Stomachache Bloating Belching Gas Indigestion Reflux Poor Appetite Difficulty Swallowing Nausea Vomiting Vomiting Blood Constipation Diarrhea/Loose Stool Bloody Stool Black Stools Hemorrhoids
Muscoskeletal Symptoms (Check if you are or have experienced any pain, numbness, or weakness in the following):	Shoulders Neck Arms Hands Joints Hips Knees Legs Low Back Pain Pain All Over All Over Weakness Hot Limbs Cold Limbs Lack of Strength Broken Bones
Genitourinary Symptoms:	Frequent Urination Profuse Urination Urgent Urination Poor Bladder Control Scanty Urine Dilute urine Dark Urine Cloudy Urine Blood in Urine Burning Urination Pain prior to Urination Pain during Urination Pain after Urination Kidney Infections
Neurological Symptoms:	Fainting/Syncope Dizziness Vertigo Drowsiness Loss of Balance Poor Memory Convulsions Paralysis Stroke/CVA/TIA Seizures Numbness
Dermal/Skin Symptoms:	Bags under Eyes Dark Circles under Eyes Lumps in Groin Lumps Under Arms Rashes/Hives Bruise Easily Blood not Clotting Discoloration Itching Acne Psoriasis Brittle Nails Dry Lips Dry Mouth Dry Hair Dry Skin Dry Eyes Premature Graying Hair Falling Out
Diet and Lifestyle Symptoms:	Vegetarian Vegan Healthy Diet Raw Food Diet High Protein/Low Fat Eat a lot of Dairy Eat a lot of Sweets Artificial Sweeteners Extreme Thirst Thirst without desire to drink Underweight Normal for Height Overweight
Emotional Symptoms:	Insomnia Vivid Dreaming Unclear Mind Forgetful Difficulty expressing emotions Unrestrained Joy Often sad Cry uncontrollably Anxiety Irritability Terror Angry
Male Symptoms (Only):	Impotence Genital pain Genital Sores Testicular Lump(s) Penile Discharge Nocturnal Emissions Low Sexual Desire High Sexual Desire
Female Symptoms (Only):	Contraceptives Breast Lump(s) Ovarian Cysts Vaginal Discharge Sores on Genitals Endometriosis Uterine Prolapse Loss of Head Hair Low Sexual Desire High Sexual Desire Early Menses Late Menses Irregular Menses Pain before Menses Pain during Menses Pain after Menses Bleeding between Menses PMS Heavy Menses Light Menses Amenorrhea Clotting Brownish Watery,Thin & Bright Red Normal Red Flooding/Trickling Stops & Starts Menopausal
Date of Last Pap Smear:
Number of Pregnancies:
Number of Abortions:
Number of Births:
Number of Miscarriages:
Pregnant, if yes how many months:
Age of 1st Menses
Time between Menses:
Duration of Menses:
First date of last Menses: