Intake form Medical HistoryThis Information is essential for the diagnosis procedure and helps us to provide you with a better treatment. Please fill out as accurately as you can.You can adjust the size of the text window of some fields. There's no limit of the amount of the text you typed in.THIS INFORMATION IS CONFIDENTIALYour Name (required) Your Email (required) Your Social Security Number Your Health insurer: Your Health insurer Relationship number: Your Care pack: Your phone number(s) Your address/residence Name/Adres/Residence of your family doctor Birth date: Height: Weight: What is your principle complaint?What has been diagnosed (By M,D.)?Any problems during your birth?Vaccination history. Any reactions that you remember?Any unusual vaccinations?Childhood Illnesses? Any surgery or accidents?Age: Age: Age: What kind of adolescence Illnesses did you have? Are there any surgery or accidents?Age: Age: Age: What about adulthood illnesses? Are there any surgery and/or accidents?Age: Age: Age: Age: Age: Please note all major illnesses in your immediate family, like diabetes, heart disease, blood pressure, neurological disorders, psychological disorders, blood disorders, orthopedic disorders etc.Are you taking any medication? Please note all medication, herbs, vitamins, and minerals you take even if you take them only occasionally.Do you have any scars? Note location of all operation or injury scars (even minor ones).SYMPTOM LISTCheck any problem, disease, or symptom you have now. Mark items that affected you in the past.Skin:eczemaacneskin rashesdermatitisfurunclesfungal infectionswartspsoriasisHeart and vascular:fast pulse (over 100 beats/min.)slow pulse (less than 60 beats/min)palpitationirregular pulsefeeling of pressure in the chestshort of breathchest paindizzinessmigraineheadache with nauseacold hands/feetRaynaud's diseaseflushed faceanemiahigh blood pressurelow blood pressurecold sweatsred facefeel dizzy or faint when standing up quickly or standing for a long timeGastrointestinal:constipationdiarrheano appetitestomach painindigestionheartburnintestinal gasbelchingulcergastritislack of stomach acidhemorrhoidsileocecal valvespasmperitonitispancreatitisirritable bowelpolypsGI stromal tumorsRespiratory:asthmabronchitisemphysemacoughwheezepneumonialung abscesspneumothorax (collapsed lung)Hormonal imbalance:low thyroidoveractive thyroiddiabeteshypoglycemiablood sugarOther hormone imbalance: Male:impotencepremature ejaculationprostate gland problemvasectomy (sterilization)infertilityFemale:menstrual problemscramping heavy/light/irregular periodsPMS (Premenstrual syndrome)emotional reactionsmenopause symptomstubal ligationinfertilitylow libidoAutoimmune and inflammatory conditions:Hashimoto's disease (thyroid)rheumatismsystemic lupuserythematosus colitisCrohn's diseasealopecia (baldness)allergy foodallergy atopicdermatitisneurodermatitiscellulitis (skin infection)sinus allergyvulvitislow immunityEffects of focal infections:rheumatic diseaserheumatic feverarthritisskin diseaseConnective tissue or ligament diseases:Myofascial pain syndromefibromyalgiatendinitisligaments pericarditisconstant slight feverglomerulonephritisplantar fasciitisscarlet feverear infectionsstreptococci infectionsstaphylococci infectionseasily catch cold or sore throatswollen glandsEar, nose & throat:deafnesstinnitus (ringing in the ear)itchy earear painfrequent ear infectionssinus head achesyellow mucusstuffy nosepost-nasal dripdry throatitchy throatconstant sinus congestionstreptococcithroat infectionssore throatOral diseases:bleeding gumsperiodontitisdental abscess mumpsstomatitis (inflammation of the mouth)TMJ (temporomandibular joint dysfunction)toothaches without cavitiesGeneral:insomniapsychosomatic weaknessexhaustionemotional problems (angry, irritable, depressed, anxious)difficult concentrating on a taskeasily get car sick, sea sick, or air sickno appetite for breakfastmoody in morningsunusual sweating (palm, sole, or elsewhere)never sweatBefore noon time:no energyfeel spacey, scattered mindedenergetic all evening through midnight, but hate to wake up early in the morninglong shower or bath makes you feel dizzy or faintMedication and drugs:birth control pillcigarettesalcoholcocainemarijuanaPlease drop here your complete life story as detailed as possible. Especially the ones according to you that are responsible for your complaint:State here as honestly and as detailed possible what your expectations are of the session:For cosmetic acupuncture please specify oversensitivity or allergy for cremes and other fluids:Attachment(s) (for cosmetic acupuncture please provide detailed photos of your face)deldeldeldeldelAdd fileSubmit a Comment Cancel replyYour email address will not be published. Required fields are marked *CommentName * Email * Website