Questionnaire for Acupuncture

Patient Name: ______________________ DOB: __________ Primary Care Physician: ______________________________ Questionnaire for Acupuncture Below is an...
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Patient Name: ______________________ DOB: __________ Primary Care Physician: ______________________________

Questionnaire for Acupuncture Below is an important questionnaire for you to complete in preparation for your acupuncture appointment. Information provided within this document will assist the physician in developing a thorough plan of care for your visit. Please complete this form and return to our office. Once your completed questionnaire is received, we will contact you for appointment scheduling. You may return this form in person or via mail or fax to your appointment location below. We are unable to receive completed patient forms via email. University Office at Quadrangle

FAX: 407-882-4751

Lake Nona (Medical City) Office at Gateway

FAX: 407-266-4910

3400 Quadrangle Blvd ● Orlando, FL 32817 9975 Tavistock Lakes Blvd Suite 160 ● Orlando, FL 32827

We look forward to seeing you at your appointment. UCF Health In addition to your medical history, it is important to tell your doctor (please check below): ☐ if you have ever fainted, had a seizure, or had an unusual reaction to a medical treatment ☐ if you have a pacemaker or any other implanted device ☐ if you have had a joint replacement, spinal surgery, or other surgery ☐ if you have ever had surgery involving your chest (heart, lungs, etc…) ☐ if you have a bleeding disorder ☐ if you are taking blood thinners such as Coumadin (a.k.a. warfarin), clopidogrel (a.k.a. Plavix), aggrenox, heparin, lovenox, dabigatran (a.k.a.Prada), rivaroxaban (a.k.a. Xarelto), aspirin or any other medication that may thin your blood. Please list any blood thinning medications here: ________________________________________________________________________ ☐ if you have a damaged heart valve or other cardiac problem ☐ if you are at increased risk of infection (including medications that can weaken the immune system or conditions such as HIV/AIDS) ☐ if you have any psychiatric disorder – please list: ___________________________________ ☐ if you are taking chemotherapy ☐ if you have a low white blood cell count ☐ if you are pregnant Please list any important information regarding the items above in the space below. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Patient Name: ___________________________________ DOB: __________ 1. List in order of importance the reasons you wish to see the doctor. 1 2 3 4 5

2. Please circle the answers that apply to you at least 80% of the time. Be nonjudgmental and don't think about the answers too much. Leave blank any boxes that do not apply to you or if you are unsure. Your honesty will result in a better treatment. Please circle ONE answer for each of the following categories: Five Phase Questions

Wood

Fire

Water

Earth

Metal

My favorite season

Spring

Summer

Winter

Harvest (late summer)

Autumn

My favorite color

Blue-Green (turquoise)

Red

Dark Blue or Black

Yellow (earth tones)

White

My favorite flavor

Sour, citrus, acidic

Bitter, roasted

Salty

Sweetness

Spicy, flavorful

My predominant emotional tendency

I tend to get angry.

I am excitable.

I get scared.

I tend to worry.

I tend to feel sad.

My predominant psychological characteristic

I tend to be anxious and irritable.

I am joyful and creative.

I am willful and ambitious.

I often find myself in deep thought.

I tend to get depressed.

My usual reaction to stress

I clench. My muscles get tight.

I tend to cry.

I tremble. My body feels shaky.

My stomach feels upset.

My chest feels tight.

My fingernails can be described as

Elongated

Long and narrow

Crescent moon

Triangular

Rectangular

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Patient Name: ___________________________________ DOB: __________

3. Treatments I have tried in the past: __Physical Therapy

__Chiropractor

__Massage Therapy

__Psychotherapy (counseling)

__Injections

__Other (please explain):_____________________________________ _________________________________________________________

4. On the figures below, mark the area or areas where you have pain OR other problems. Please be as accurate as possible with the locations.

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Patient Name: ___________________________________ DOB: __________ 5. Please describe your symptoms in more detail below. PLEASE NOTE THAT EACH COLUMN OF THE TABLE CORRESPONDS TO THE PICTURES ON THE PREVIOUS PAGE

Problem Assessment SIDE OF BODY

Problem Assessment BACK OF BODY

Problem Assessment FRONT OF BODY

Location: Left/Right/Both

Location:

Location:

How long have you had this problem? (be specific):

How long have you had this problem? (be specific):

How long have you had this problem? (be specific):

What makes the problem better? What makes the problem better? What makes the problem better?

What makes the problem worse?

What makes the problem worse?

What makes the problem worse?

Any associated symptoms?

Any associated symptoms?

Any associated symptoms?

Circle the quality of your condition: • Constant • Occasional • Sharp • Pressure • Dull • Burning

Circle the quality of your condition: • Constant • Occasional • Sharp • Pressure • Dull • Burning

Circle the quality of your condition: • Constant • Occasional • Sharp • Pressure • Dull • Burning

Please rate the severity of condition (1=best : 10=worst)

Please rate the severity of condition (1=best : 10=worst)

Please rate the severity of condition (1=best : 10=worst)

1 2 3 4 5 6 7 8 9 10

1 2 3 4 5 6 7 8 9 10

1 2 3 4 5 6 7 8 9 10

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Patient Name: ___________________________________ DOB: __________ 6. Please place a check in the box next to the statements that apply to you at least 80% of the time. Be nonjudgmental and don't think about the answers too much. Leave blank any boxes that do not apply to you or if you are unsure. Your honesty will result in a better treatment.

I can be characterized as creative, passionate, dramatic, and impulsive. I frequently exude heat and often feel flushed and sweaty. I tend towards sexual hyperactivity. I have experienced chest pains or palpitations (racing heart rate). I tend to be talkative or noisy. I am the life of the life of the party. I can be characterized as authoritative, imposing, and impatient. I am competitive. I like to win. I have neck or lower back pain. I have insomnia (difficulty sleeping). I occasionally have headaches.

I can be characterized as intelligent and very analytical, but often indecisive. I have a history of recurrent urinary tract infections, urethritis, and kidney problems. I tend to have poor stamina and tire easily. I have diffuse low back pain. I sometimes have digestive problems. I can be characterized as private, cautious, and secretive. I have problems with motivation, self-discipline, and making decisions. I tend to have recurrent sore throats, tonsillitis, kidney infections, or kidney stones. I tend to be chilly with cold hands. I dislike cold. I experience lower back pain, knee pain, and achy joints when I am tired.

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Patient Name: ___________________________________ DOB: __________

I can be characterized as irritable, anxious, and emotionally volatile at times I tend to harbor grudges and have explosive anger. I get tension headaches or stress-related headaches. I get muscle cramps and often have insomnia. I an sensitive to many foods. I get stomach cramps and/or diarrhea. I sometimes feel like I digest my food slowly. I can be characterized as clear thinking and decisive. When I get agitated, I can't sleep. I tend to grind my teeth and have tight jaws. I have muscle aches and cramps. I need to exercise, move, and stretch or I don’t feel right.

I can be indecisive. I wish I were more self-confident. I am sensitive to ridicule or criticism. I have neck pain and shoulder tension. This can cause headaches. I tend to have lateral or side hip pain. I have digestive problems due to my gall bladder. I can be characterized as timid or introverted. I am sensitive to caffeine, and I need it as a pick-me-up. I get migraine headaches and tension headaches. My palms tend to be sweaty requiring a handkerchief. I have sensitive eyes. I'm near-sighted.

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Patient Name: ___________________________________ DOB: __________

I can be characterized as round and fleshy with full lips, calm, and peaceful. I often have abdominal bloating and diarrhea. I have had anemia and menstrual or fertility problems. I have varicose veins or cold feet. I take care of others, even at my own expense. I enjoy life, food, and drink. I am a pleasure seeker. I have been diagnosed with heartburn, GI reflux disease (GERD), or peptic ulcer disease. I sometimes overindulge in food and drink. I gain weight easily. I develop digestive problems during times of stress or anxiety. My mood can swing from pleasant to angry and irritable.

I have recurrent sinus infections, colds, or respiratory infections. I have poor digestion and experience stomachaches. I focus on my bowel habits. I tend to be thin. I have a strong belief in honor, duty, responsibility, and respect for the law. I tend to feel tired and a little sad. I get depressed easily. I have a history of respiratory problems such as bronchitis, pneumonia, asthma, COPD, etc. I have been diagnosed with Irritable Bowel Syndrome (IBS), which is characterized by alternating episodes of diarrhea and constipation. I have skin problems and allergies. I am organized and methodical. I am honest and obey the rules.

7. Please provide any additional information not previously covered that will be important for the doctor to know: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ [End of Patient Acupuncture Worksheet] Page 7 of 10

Patient Name: ___________________________________ DOB: __________

TREATMENT PLAN (For physician use only)

Working Diagnoses: 1._______________________________________________ 2._______________________________________________ 3._______________________________________________ 4._______________________________________________ 5._______________________________________________

Page 8 of 10

Patient Name: ___________________________________ DOB: __________ Assessment/Plan

Impression:

TCM Diagnosis:

Treatment Notes:

Post-Treatment Comments:

Recommendations for Future Treatments/Plan:

Other Comments:

Post-Treatment Comments:

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Patient Name: ___________________________________ DOB: __________

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