CONFIDENTIAL HEALTH…

                                                  CONFIDENTIAL HEALTH HISTORY

Welcome! Please take the time to fill out this questionnaire fully. Your answers are strictly confidential. If you have any questions, please feel free to ask.


Today's Date _________________

Name _______________________________________ Date of Birth _____________________________
Address________________________________________ City ___________ State _______ Zip ____________
Tel: Work _________________________ Home ________________________ Cell ______________________
E-mail _____________________________                                              Age _______ Gender __________
Occupation____________________________________ Referred by __________________________________
Emergency Contact Name & Tel# ______________________________________ Relationship _____________


What would you like treated by acupuncture? _____________________________________________________
How and when did this condition develop? _______________________________________________________
__________________________________________________________________________________________
How has this condition affected your daily activities? _______________________________________________
What medical diagnosis have you received, if any? _________________________________________________
What kinds of treatment or therapy have you tried? ________________________________________________

Are you currently pregnant? ___________                         Are you presently trying to become pregnant? ____________


                                Please shade any areas of pain or distress on the diagram below:
Medical History: Please check off any current or former conditions and include dates as well as any relevant information.

   Allergies                                  Heart Disease                               Insomnia
   Asthma                                     Pacemaker                                   Fatigue
   Sinusitis                                  Mitral Valve Prolapse                       Anxiety
   Frequent colds                             Hypertension                                Depression
   Frequent childhood illnesses               Hypotension                                 Mood swings
   Diabetes                                   Varicose veins                              Irritability
   Hypoglycemia                               Emphysema                                   Panic attacks
   Sugar cravings                             Shortness of breath                         Palpitations
   Food cravings                              Chronic cough                               Dizziness
   Bloating/gas                               Nose bleeds                                 Vertigo
   Constipation                               Lymph Nodes removed                         Difficulty concentrating
   Diarrhea                                   Lymph nodes enlarged                        Forgetful
   Excess appetite                            Eczema                                      Hair loss
   Excess thirst                              Psoriasis                                   Dry/brittle hair
   Dry mouth                                  Itchy Skin                                  Premature greying
   Weight loss                                Dry skin                                    Poor vision
   Weight gain                                Other skin rashes                           Dry eyes, itchy eyes
   Decreased appetite                                                                     Eye strain/pain
   Increased appetite                         Latex allergy                               Seeing spots
   Stomach cramping/pain                      Brittle nails                               Ear pain
   Acid reflux                                Aches/pains                                 Ringing in ears
   Hiatal hernia                              Muscle spasms                               Clogged ears
   Hyperthyroid                               Arthritis                                   Dental problems
   Hypothyroid                                Numbness                                    Cold sores
   Seizures                                   Neuropathies                                Bleeding gums
   Headaches                                  Urinary difficulty                          Other:
   Migraines                                  Urinary frequency
   Hepatitis A/B/C                            Water retention
   Herpes                                     Cold hands/feet
   Venereal disease                           Cold body temp
   AIDS/HIV                                   Hot body temp
   Tuberculosis                               Night sweats
   Alcoholism                                 Hot flashes
   Multiple Sclerosis                         Excessive sweating


Vaccination History: Any reaction that you remember? Any unusual vaccinations?

__________________________________________________________________________________________

Please describe any significant injuries/trauma, illnesses, or surgeries:

Birth trauma, if any __________________________________________________________________________
Age ______________________________________________________________________________________
Age ______________________________________________________________________________________
Age ______________________________________________________________________________________
Age ______________________________________________________________________________________
Age ______________________________________________________________________________________
Age ______________________________________________________________________________________
Scars: from injury/surgery (even minor): ____________________________________________________________

Medications: Please list all medications (including over-the counter), herbs, vitamins and minerals you are taking.




Family Medical History: Please list all major illnesses in your close family such as diabetes, heart disease, high blood
pressure, neurological disorders, psychological disorder, orthopedic disorders, etc.




Men:
 Prostatitis         Impotence

Other




Women:
Age at first menses ___________ days between cycles ___________ duration of flow
Color/quality of blood_____________________________ birth control type

Check all that apply:
  PMS, symptoms
  Heavy flow                                     Pain/discomfort before period
  Light flow                                     Pain/discomfort during period
  No flow

Number of pregnancies _______       deliveries _______
Pregnancy complications ________________________________________________________________

Age at menopause (if applicable)_______ Symptoms, if any
Hormone replacement (if applicable)




PLEASE NOTE: This office has a 24 hour cancellation policy. Please notify us well in advance if you
need to change or cancel your appointment. Thank you!
                                         Informed Consent

I consent to Acupuncture treatments and related procedures associated with Oriental Medicine, by
Heidi Botnick, L.Ac. I have discussed the nature and purpose of my treatment with her and I
understand that the methods of treatment may include but are not limited to acupuncture, moxibustion,
cupping, gua sha, Tui-Na, electrical stimulation, Chinese herbology and nutritional counseling.

I have been informed that acupuncture is a safe method of treatment, but that it may have minor side
effects, including bruising, numbness or tingling near the needling sites that may last a few days, and in
rare cases, dizziness or fainting. This office uses sterile, disposable needles and maintains a clean and
safe environment. Burns and scarring are potential risks of moxibustion. There may be some bruising
after cupping and gua sha that may last a few days. There have been very rare instances reported of
spontaneous miscarriage and pneumothorax. I understand that while this document describes the major
risks of treatment, other side effects and risks may occur.

The herbs and nutritional supplements that are used are traditionally considered safe in the practice of
Oriental Medicine. I understand that some herbs may be inappropriate during pregnancy. If I
experience any gastro-intestinal upset or allergic reactions to the herbs I will stop taking them and
immediately inform the acupuncturist.

I will notify the acupuncturist should I become pregnant or if I am trying to become pregnant.

I do not expect the acupuncturist to be able to anticipate and explain all possible risks and
complications of treatment. I wish to rely on the acupuncturist to exercise judgment during the course
of treatment, and decide what she thinks is in my best interest, based upon the facts that are known at
the time. I understand the practitioner and administrative staff may review my medical records and
reports, but all of my records will be kept confidential and will not be released without my written
consent.

By voluntarily signing below, I show that I have read or have had read to me this consent to treatment.
I have been told about the risks and benefits of acupuncture and other procedures and have had an
opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my
present condition and for any future conditions for which I seek treatment.



Signature of Patient or Patient's Representative



Date