New Patient Intake Form New Patient Intake Form Step 1 of 7 14% Please Note: This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to any person except when you have authorized us to do so. * indicate required field.Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Home PhoneMobile Phone*Work PhonePrimary email* Enter Email Confirm Email Date of birth* MM slash DD slash YYYY Age* Weight Occupation Referred By First Last Physician Physician's PhoneMarital Status Married Single Divorced Emergency Contact Name First Last Emergency Contact TelephoneFinancial ResponsibilityInsurance Company* ID #* Primary Insurance: Co-Pay* Yes No Co-Pay AmountName of Insured* First Last Relationship to Patient* Self Spouse Parent Secondary Insurance Name of Insured First Last Acknowledgment of quotation*I understand that this is a quotation of benefits and is NOT a guarantee of payment, and the agreement is between the Insurance Carrier and me. I authorize all payment from my insurance carrier directly to this office with the understanding that all monies be credited to my account upon receipt. Any denial of payment becomes my responsibility (patient). Please note: recent changes within insurance companies may necessitate action on the part of the patient to work with their insurance company prior to, and to avoid, final denials. Yes Patient Name First Last Initial (Electronic Signature)* Today's Date* MM slash DD slash YYYY Card Number*24-HOUR CANCELLATION POLICY We take pride in the quality of care we offers our patients. In order to do this, it is necessary to enforce a cancellation policy that requires a 24-hour cancellation notice prior to your appointment time. If sufficient time is not given, I understand that a fee of $25 will be charged for broken appointments, barring emergencies. Card Expiration date (MM/YY)* Security Code* I - Major SymptomsChief Complaint* Please list in order of importance what symptoms are of concern to you, and duration of each.* II - DescriptionPlease list what makes your condition better, what makes it worse, frequency of occurrence, and how your day-to-day activities are affected.* III - GoalsWhat outcome would you like to achieve through your work with Mountaintop Acupuncture?* IV. Additional informationPlease provide any of the following optional information that may be relevant to your visit.Additional information about this condition that was not asked above: For Women1. Are you pregnant now? Yes No Unsure 2. Indicate Number of occurrences:Live BirthsPregnanciesMiscarriagesAbortions3. Age:First PeriodMenopause (if applicable)4. Date:Last Pap SmearLast Mammogram5. History of an Abnormal Pap Smear Yes No If yes, what/when? 6. Is Your Menstrual Cycle Regular? Yes No Average number of days of flow The flow is Normal Heavy Light The color is Normal Dark Purple Light Brown Brown 7. Do you have the following menstruation related signs or symptoms? Difficulty with orgasm Cramps PMS Heavy Vaginal discharge between periods Pain with Intercourse Nausea Bleeding between periods Blood Clots Breast Distension Vaginal Discharge For Men1. Do you have any bothersome urinary symptoms? Yes No Please describe 2. Check all that apply Erectile Dysfunction Difficulty with orgasm Pain or Swelling of the Testicles Impotence/Erectile Premature Ejaculation Feeling of coldness or Dysfunction Numbness in genitalia Frequent need to Urinate at Night Lack of sex drive 3. Do you get up at night to urinate? Yes No How Often? 4. To what extent do these conditions interfere with your daily activities (work, sleep, socializing, sex, etc.)? 5. Have you sought medical intervention for these problems? If so, when? 6. What treatments have you tried for these problems and how successful have they been? V - Medical & Family HistoryPlease check all that apply and state how you are related to the family member with that conditionYou* Heart Disease Cancer Hypertension Stroke Asthma Allergies Migraines/Headaches Depression Other mental health Substance abuse Osteoporosis Diabetes Glaucoma Gastroentological Other Mother Heart Disease Cancer Hypertension Stroke Asthma Allergies Migraines/Headaches Depression Other mental health Substance abuse Osteoporosis Diabetes Glaucoma Gastroentological Other Father Heart Disease Cancer Hypertension Stroke Asthma Allergies Migraines/Headaches Depression Other mental health Substance abuse Osteoporosis Diabetes Glaucoma Gastroentological Other Sibling Heart Disease Cancer Hypertension Stroke Asthma Allergies Migraines/Headaches Depression Other mental health Substance abuse Osteoporosis Diabetes Glaucoma Gastroentological Other Maternal Grandparent Heart Disease Cancer Hypertension Stroke Asthma Allergies Migraines/Headaches Depression Other mental health Substance abuse Osteoporosis Diabetes Glaucoma Gastroentological Other Paternal Grandparent Heart Disease Cancer Hypertension Stroke Asthma Allergies Migraines/Headaches Depression Other mental health Substance abuse Osteoporosis Diabetes Glaucoma Gastroentological Other If "other" checked above, provide details: VI - Medications/SupplementsMedications/Supplements Medications you are currently taking(please include prescriptions medicine, supplements, herbal supplements, and over-the-counter medicines you take on a regular basis, along with dosages and brands, if known) Allergies to medications, chemicals, or foods VII - Nutrition1. Do you follow a special diet? Yes No 2. What do you eat on a typical day?BreakfastLunchDinnerVIII - Social History 1. How much per day do you do of the following:Coffee, TeaSoft DrinksAlcoholTobaccoOther2. Do you have any known history of toxic exposures? Yes No 3. If so, please list which and when you first noticed symptoms? 4. In the past year, how many days have been significantly affected by your health? 5. How many days did you feel generally poor? 6. How many times were you in the hospital? IX - Sleep1. Do you have trouble (check all that apply) Falling Asleep Staying Asleep Dream-Disturbed Sleep Waking around ____ am/pm and not being able to fall back to sleep 2. How many hours do you usually get per night during the week? 3. Do you wake feeling rested? Yes No X - ExerciseDo you exercise? Yes No If yes, please describe your current exercise regime:(list hours per week, and activities) XI - Emotions1. Choose two emotions that dominate your life: 2. Do you have (check all that apply) Panic attacks Depression Anxiety Nervousness Fear attacks Poor memory Difficulty concentrating Mood swings Easily angered 3. Who would you describe as your source of primary social support?#1#24. Are you in a relationship? Yes No 5. How do you feel about your relationship? 6. How do you deal with stress? How do you relax?7. Please list and briefly describe the most significant events in your life:XII - SurgeriesPlease list type of surgeries and date XIII - Additional informationPlease provide additional information you think is relevant for us to know that may not be covered above: Health HistoryReview of Systems General (Past)Check all that apply Poor appetite Excessive appetite Insomnia Fatigue Fever Night sweats Sweat easily Chills Localized weakness Poor coordination Bleed or bruise easily Catch cold easily Change in appetite Strong thirst Other: General (Current)Check all that apply Poor appetite Excessive appetite Insomnia Fatigue Fever Night sweats Sweat easily Chills Localized weakness Poor coordination Bleed or bruise easily Catch cold easily Change in appetite Strong thirst Other: Skin & Hair (Past)Check all that apply Rashes Hives Itching Eczema Pimples Dryness Tumors, lumps Skin & Hair (Current)Check all that apply Rashes Hives Itching Eczema Pimples Dryness Tumors, lumps Head & Neck (Past)Check all that apply Dizziness Fainting Neck Stiffness Enlarged lymph glands Headaches Concussions Other Head & Neck (Current)Check all that apply Dizziness Fainting Neck Stiffness Enlarged lymph glands Headaches Concussions Other Eyes (Past)Check all that apply Blurred vision Visual changes Poor night vision Spots Cataracts Glasses/contacts Eye inflammation Other Eyes (Current)Check all that apply Blurred vision Visual changes Poor night vision Spots Cataracts Glasses/contacts Eye inflammation Other Nose, Throat, Mouth (Past)Check all that apply Nose bleeds Sinus Infections Hay fever or allergies Recurring sore throats Grinding teeth Difficulty swallowing Nose, Throat, Mouth (Current)Check all that apply Nose bleeds Sinus Infections Hay fever or allergies Recurring sore throats Grinding teeth Difficulty swallowing Cardiovascular (Past)Check all that apply High blood pressure Low blood pressure Blood clots Palpitations Phlebitis Chest pain Irregular heart beat Cold hands/feet Fainting Difficult breathing Swelling of hands/feet Other Cardiovascular (Current)Check all that apply High blood pressure Low blood pressure Blood clots Palpitations Phlebitis Chest pain Irregular heart beat Cold hands/feet Fainting Difficult breathing Swelling of hands/feet Other Respiratory (Past)Check all that apply Asthma Bronchitis Frequent Colds COPD Pulmonary disease Pneumonia Cough Coughing blood Production of phlegm Other Respiratory (Current)Check all that apply Asthma Bronchitis Frequent Colds COPD Pulmonary disease Pneumonia Cough Coughing blood Production of phlegm Other Gastro-Intestinal (Past)Check all that apply Nausea Vomiting Diarrhea Belching Blood in stools/black Stool soft/dry Bad breath Rectal pain Hemorrhoids Constipation Pain or cramps Indigestion Gall bladder disorder Gas Other Gastro-Intestinal (Current)Check all that apply Nausea Vomiting Diarrhea Belching Blood in stools/black Stool soft/dry Bad breath Rectal pain Hemorrhoids Constipation Pain or cramps Indigestion Gall bladder disorder Gas Other Genito-Urinary (Past)Check all that apply Kidney stones Pain or urination Frequent urination Blood in urine Urgency to urinate Unable to hold urine Other Genito-Urinary (Current)Check all that apply Kidney stones Pain or urination Frequent urination Blood in urine Urgency to urinate Unable to hold urine Other Male (Past)Check all that apply Pain/Itching genitalia Genital lesions/discharge Impotence Weak urinary stream Lumps in testicles Other Male (Current)Check all that apply Pain/Itching genitalia Genital lesions/discharge Impotence Weak urinary stream Lumps in testicles Other Female (Past)Check all that apply Frequent UTI’s Frequent vaginal infections Pain/itching of genitalia Genital lesions/discharge Pelvic inflammatory disease Abnormal pap smear Irregular menstrual periods Painful menstrual periods Premenstrual syndrome Abnormal bleeding Menopausal syndrome Breast lumps Hot flashes Other Female (Current)Check all that apply Frequent UTI’s Frequent vaginal infections Pain/itching of genitalia Genital lesions/discharge Pelvic inflammatory disease Abnormal pap smear Irregular menstrual periods Painful menstrual periods Premenstrual syndrome Abnormal bleeding Menopausal syndrome Breast lumps Hot flashes Other Neurological (Past)Check all that apply Frequent headaches Seizures Tremors Numbness/tingling of limbs Concussion Pain Paralysis Other Neurological (Past)Check all that apply Frequent headaches Seizures Tremors Numbness/tingling of limbs Concussion Pain Paralysis Other Psychological (Past)Check all that apply Depression Anxiety/stress Irritability Treated for emotional or Psychological problems Other Psychological (Current)Check all that apply Depression Anxiety/stress Irritability Treated for emotional or Psychological problems Other Infection screening (Past)Check all that apply HIV TB Hepatitis Gonorrhea Chlamydia Syphilis Genital warts Herpes: oral Herpes: genital Infection screening (Current)Check all that apply HIV TB Hepatitis Gonorrhea Chlamydia Syphilis Genital warts Herpes: oral Herpes: genital Musculoskeletal (Past)Check all that apply Stiff neck/shoulders Low back pain Back pain Muscle spasm/twitching/cramp Sore, cold, or weak knees Joint pain Musculo-Skeletal (Current)Check all that apply Stiff neck/shoulders Low back pain Back pain Muscle spasm/twitching/cramp Sore, cold, or weak knees Joint pain Δ