ACUPUNCTURE REGISTRATION FORM

ACUPUNCTURE PATIENT INFORMATION

Name

Address

City

State

Zip

SS#

Date of Birth

Age

Occupation

Employer

Spouse’s Name

Spouse’s Employer

# of children

Name of family doctor

How did you hear about this office?

Financial Policy

NOTICE TO OUR NEW PATIENTS:

It is the policy of this office for patients to make payment (cash payments, co-payments, etc.) for services rendered prior to each visit. Other payment arrangements (ie. payment plans, etc) must be specifically discussed and/or approved by this office prior to treatment initiation. Deductible payments will be billed on receipt of insurance EOB. Formatted text

Initials:

NOTES / COMMENTS

Most insurance companies do not have coverage for acupuncture. Please let us know if your insurance carrier has coverage for acupuncture prior to your treatment. In any case, you will be financially responsible for your acupuncture treatments according to our financial policy.

PHONE NUMBERS, E-MAIL, & EMERGENCY CONTACT

Home #:

Cell:

Other:

E-Mail Address:

If yes, please initial:

Emergency Contact Information

Name

Relationship

Best contact phone #:

Additional information:

Important Questions:

Have you ever had acupuncture?

Yes No

If yes, when was the last treatment:

Have you ever had acupuncture for this condition?

Yes No

If yes, when was the last treatment:

Have you ever had a bad reaction to acupuncture?

Yes No

Explain:

Do you have any bleeding disorders?

Yes No

Explain:

Are you on any blood thinners (Coumadin)?

Yes No

What medicine:

Do you currently or have you ever had an infectious disease?

Yes No

If yes, explain:

Are you currently pregnant?

Yes No

Are you presently trying to get pregnant?

Yes No

Signature of Patient/Parent/Guardian/POA

Date

Reviewed By:

CURRENT COMPLAINT(S) / CONDITION(S)

What conditions do you want treated with acupuncture? Reasons for your visit:

Add new row

How and when did your problem start?

Is your condition?

Constant (100% of day) Frequent (75% of day) Occasional (50% of day) Intermittent (25% of day)

Describe the condition:

Does it interfere with?

Work

Sleep

Recreation

Daily Activity

Nothing

Other

What other activities does it interfere with?

What tests have you had?

X-rays

MRI

EMG

Ultrasound

Lab work

Other:

What treatment have you had?

Medication

Injection

Surgery

Other

Has the treatment helped?

Yes No

If yes, explain:

How is your energy?

High Low

Do you fatigue easily?

Yes No

Do you have:

Depression

Anxiety

Nervousness

Panic attacks

Bad temper

Poor memory

Poor concentration

Other Stress

Explain:

Do you have difficulty with:

Falling asleep

Staying asleep

nightmares

Waking up at

DATES OF MOST RECENT EXAMS

Spinal X-ray

Physical exam

Chest X-ray

Blood work

Other

LIST ALL PREVIOUS INJURIES, HOSPITALIZATIONS, AND/OR SURGERIES

Add Injuries/Falls

Add Surgeries

Add Fractures

Other hospitalizations or information:

Add new row

SOCIAL HISTORY

drinks per week

Packs per day

# of years

PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS please check any that apply to you

Constitutional

Bad general health

Recent weight change

Fever

Fatigue

Headaches

Eyes

Eye disease/injury

Glasses or contact lens

Blurred / double vision

Ear, Nose, Throat

Hard of Hearing

Ringing in ears

Vertigo

Sinus problems

Nose bleeds

Sore throat / voice change

Swollen glands

Neurological

Seizures or Epilepsy

Numbness / Tingling

Tremors

Stroke

Multiple Sclerosis

Musculoskeletal

Joint Pain / Stiffness

Joint Swelling

Arthritis

Osteoporosis

Chronic fatigue

Fibromyalgia

Cardiovascular

Chest pain / Palpitations

Dizziness / Fainting

Shortness of breath

Swelling in hands / feet

High blood pressure

High cholesterol

Heart attack

Congestive heart failure

Gastrointestinal

Heartburn / Belching

Nausea/Vomiting

Diarrhea/Constipation

Blood in stools

Gall bladder problems

Liver problems

Ulcers

Genito-urinary

Pain / Difficulty urinating

Blood in urine

Incontinence

Kidney stones

Kidney problems

Respiratory

Cough / excessive mucus

Congestion / colds / flu

Wheezing

Asthma

Emphysema

Pneumonia

Psychiatric

Anxiety / Depression

Mood Swings

Difficulty sleeping

Memory loss

Hematologic/Lymphatic

Slow to heal after cuts

Bleed or bruise easily

Anemia

Enlarged glands

Endocrine

Excessive thirst / urination

Heat or cold intolerance

Skin becoming drier

Diabetes (Type I)

Diabetes (Type II)

Thyroid disorder

Integumentary (skin, breast)

Rash / Sores / Hives

Lesions

Breast pain or lump

Dermatitis/Eczema/dry skin

Allergic/Immunologic

Food allergies

Airborne allergies

Systemic Lupus

Cancer

HIV/AIDS

Other (see below)

Other:

Alcoholism

Infertility

Menstrual disorders

Insomnia

Anxiety / depression

FAMILY HISTORY

Add new row

MEDICATIONS / TAKEN FOR:

Add Medication

SUPPLEMENTS/VITAMINS/HERBS

Add Supplements/Vitamins/Herbs

ALLERGIES (Meds, seasonal, etc.)

Add Allegies

WHAT IS YOUR GOAL IN OUR OFFICE?

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/ Parent of Minor/Guardian

Date

**To the best of my knowledge, the questions on these forms have been answered accurately. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform Marion Chiropractic Clinic of any changes in my personal information, insurance changes, or medical status in a timely manner.

Initials:

Your information will be encrypted.