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Oriental medicine intake form

PATIENT INFORMATION
PATIENT INFORMATION
INSURANCE
Who is responsible for this account?___________________ Name_____________________________________ Relationship to Patient________________________ Address____________________________________ Insurance Co._______________________________ __________________________________________ Group #____________________________________ Is patient covered by additional insurance? Subscriber’s Name___________________________ Birthdate__________________SS#______________ Patient SS#_________________________________ Relationship to Patient________________________ Occupation_________________________________ Insurance Co._______________________________ Employer___________________________________ Group #____________________________________ ASSIGNMENT AND RELEASE
Emp. Address_______________________________ I, the undersigned, certify that I(or my dependent) have insurance coverage with ________________________and assign directly to Emp. Phone________________________________ __________________________all insurance benefits, if any, Spouse/Partner’s Name_________________________ otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the provider to release all Birthdate________________SS#________________ information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Occupation_________________________________ _____________________________________________________ Spouse/Partner’s Employer_________________________ ____________________________________ ________________ you?______________________________________ PHONE NUMBERS
ACCIDENT INFORMATION
H____________W____________Cell____________ Date______________________________________ Best time & place to reach you__________________ IN CASE OF EMERGENCY, CONTACT
To whom have you made a report of your accident? Name_________________Relationship___________ Attorney Name (if applicable)_____________________ Home phone____________Work phone__________ GENERAL INFORMATION
Have you had acupuncture before?
Are you currently under the care of a physician? No If Yes, for what?___________________________ Physician’s name:________________________________ Physician’s phone:_________________________ ORIENTAL MEDICINE INTAKE FORM

Name:______________________________________
Date:_______________________
PRESENT HEALTH CONCERNS: Please list your most important health concerns in order of their significance.
1. ________________________________________ Approx. Date of Onset:____________________________
Does it interfere with your:
2. ________________________________________ Approx. Date of Onset:____________________________ Does it interfere with your: 3. ________________________________________ Approx. Date of Onset:____________________________ Does it interfere with your:
Please list all medications that you are currently taking (or have used in the past two months), with dosages:
1.________________________________________
4._________________________________________ 2.________________________________________ 5._________________________________________ 3.________________________________________ 6._________________________________________ Please list any vitamins, minerals, herbs, or homeopathic remedies that you are presently taking:
1.________________________________________
4._________________________________________ 2.________________________________________ 5._________________________________________ 3.________________________________________ 6._________________________________________ Please list allergies that you have to any of the following:
Drugs:_________________________________ Foods:_______________________________________________
Other (i.e. pollen, paint, etc.):____________________________________________________________________
HEALTH HISTORY
Past Medical History:
Please list past injuries, broken bones, surgeries and hospitalizations, with approx. dates.
___________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Personal Habits:
Work Activity:
Exercise:
Do you follow any diet regimens/restrictions? If Yes, describe:_____________________________ FAMILY INFORMATION

Do you have children?
No If Yes, how many?__________Ages______________________
Are you, or could you be currently pregnant?
Please check if you have had (in the last three months)
GENERAL
 Poor appetite
Other hair or skin concerns: HEAD, EYES, EARS, NOSE, AND THROAT Concussions  Headaches (location, triggers, severity)?
Other head & neck concerns:
CARDIOVASCULAR
 High blood pressure
Other heart or blood vessel concerns: RESPIRATORY  Cough  Production of phlegm - color?________  Pneumonia Other lung related concerns: History of chronic laxative use? Other concerns with your general digestion: GENTIO-URINARY  Pain on urination If you wake to urinate, how often? Other concerns with genitals or urinary system: MUSCULOSKELETAL  Neck pain Other muscle, joint or bone concerns: NEUROPSYCHOLOGICAL  Seizures Have you ever been treated for emotional problems? Have you ever considered or attempted suicide? Other neurological or psychological concerns: GYNECOLOGY Age of first menses______ If no longer menstruating, approximate date ceased____________ First day of last menses______ Length between menses:______days Duration of period:_____days  Unusual flow ( GYNECOLOGY (continued) Changes in body or psyche prior to menstruation (“PMS”): Date of last PAP:________________ Results were: If you use birth control, what type & for how long? Have you ever used hormonal methods for contraception or period regulation? (i.e. the pill, Depo-Provera, etc.) Other gynecological concerns: PREGNANCY HISTORY Number of pregnancies______ Were your births relatively normal? Explain:
Other related concerns:
COMMENTS
Please let us know of any other concerns you would like to address:
Family History: Please fill in the boxes for each condition that applies to one of your family members.
Comments
Signature: _______________________________________

Source: http://aom.nycc.edu/files/AOMNewPatientInformation.pdf

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