Golden Valley Acupunture Center
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Fertility/Women’s Health Acupuncture/ Intake Form
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Home Address
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Home Phone
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Work Phone
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E-mail
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Birthdate
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If under 18, person responsible for your account
Name
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Emergency Contact
Name
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Contact Phone
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Occupation
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Gender
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Height
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Weight
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Whom should we thank for referring you to our office?
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Have you had acupuncture therapy before?
Yes
No
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With Whom?
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Please indicate if any of the following pertain to you: (marking “yes” does not make you ineligible for treatment, however, it may restrict some of our treatment modalities):
Hepatitis
HIV
Seizures
Pacemaker
Blood-Thinning Meds
Pregnancy
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Please indicate the use and frequency of the following:
Coffee
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Soda pop
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Water
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Alcohol
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Recreational drugs
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Tobacco
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Please list any prescription or over-the-counter medications you are presently taking:
Any prescription or over-the-counter medications you are presently taking...
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Reasons For Medication...
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What are the health problems for which you are seeking treatment?
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How long have you had this condition?
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What other forms of treatment have you sought?
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What helps your condition?
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What aggravates your condition?
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Please list any surgeries or major health incidents (accidents, etc.) in your life
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What would you like to achieve with acupuncture treatment?
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Please “check” the symptoms or conditions you experience frequently:
excessive appetite
insomnia
cough
low back pain
eye problems
loose stool/diarrhe
palpitations
shortness of breath
knee problems
jaundice
digestive problems
cold hands and feet
decreased sense of smell
hearing impairment
difficulty digesting oily foods
indigestion
vomiting
nightmares
nasal problems
ear ringing
gall stones
belching, burping
mentally restless
skin problems
kidney stones
light-colored stool
heartburn/reflux
laughing for no reason
claustrophobia
decreased sex drive
soft or brittle nails
stomach bloating
chest pain
colitis/diverticulitis
hair loss
easily angered
obsession in work
poor memory
constipation
urinary problem
difficulty in relationships, making decisions, etc
lack of appetite
sadness
hemorrhoids
dental problems
high cholesterol
recent use of antibiotics
bitter taste
fatigue
edema
asthma
allergies
dizziness
get sick easily
headaches
I usually feel warm
I usually feel chilled
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Age of first period
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Date of last period
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Number of children
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Number of days between periods (your cycle)
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Number of days of flow
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Color of flow
pale/light red
red
bright red
dark red
dark red/brown
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Amount of flow
spotting
light
even throughout
heavy
clots
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# of pads you use per day:
# of pads you use per day:
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1 st day
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2 ND day
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3 RD day
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4 th day
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+days
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Other symptoms related to menses:
Discharge
PMS
Headache
Nausea
Constipation
Diarrhea
Swollen Breasts
Mood Swings
Increased Appetite
Decreased Appetite
Insomnia
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Have you ever been diagnosed with:
fibroids
fibrocystic breasts
endometriosis
ovarian cysts
PID
polycystic ovary syndrome
STD
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Please indicate if the following pertain to you:
Do you have ringing in your ears?
Is your hair prematurely gray?
Do you have vaginal dryness?
Is your mid-cycle cervical mucus scanty or missing?
Do you have dark circles under your eyes?
Do you have night sweats?
Are you prone to hot flashes?
Would you describe yourself as “afraid” frequently?
Do you have dizziness?
Do you have knee problems?
Do you have low back pain pre-menstrually?
Is your back sore or weak?
Are your feet cold, especially at night?
Are you typically colder than those around you?
Is your libido low?
Are you often fearful?
Do you wake up at night or early in the morning because you have to urinate?
Do you have early morning loose, urgent stools?
Do you have profuse vaginal discharge?
Do you feel cold cramps during your period that respond to a heating pad?
Are you often fatigued?
Do you have poor appetite?
Is your energy low after a meal?
Do you feel bloated after eating?
Do you crave sweets?
Do you have loose stools, abdominal pain, or digestive problems?
Are your hands and feet cold?
Are you prone to feeling sluggish?
Are you prone to heaviness or grogginess in the head?
Do you have varicose veins?
Are you prone to worry?
Have you been diagnosed with low blood pressure?
Do you sweat a lot without exerting yourself?
Do you feel dizzy or light-headed, or have visual changes when you stand up fast?
Is your menstruation thin, watery, profuse, or pinkish in color?
Are you more tired around ovulation or menstruation?
Do you ever spot a few days or more before your period comes?
Have you ever been diagnosed with uterine prolapse?
Are your menstrual cramps accompanied by a bearing down sensation in your uterus?
Are you often sick, or do you have allergies?
Have you ever been diagnosed with hypothyroid or anemia?
Do you have hemorrhoids or polyps?
Are your menses scant or late?
Do you have dry, flaky skin?
Are you prone to getting chapped lips?
Are your fingernails or toenails brittle?
Are you losing hair on your head?
Is your hair brittle or dry?
Do you have diminished nighttime vision?
Do you get dizzy or light-headed around your period?
Are your lips, the inner side of your lower eyelids, or tongue pale in color?
Is your menstrual flow ever brown or black in color?
Do you feel mid-cycle pain around your ovaries?
Do you have painful, unmovable breast lumps?
Do you experience periodic numbness of your hands and feet, especially at night?
Do you have varicose or spider veins?
Do you have red cherry spots (hemangiomas) on your skin?
Do you have chronic hemorrhoids?
Does your menstrual blood contain clots?
Have you been diagnosed with endometriosis or uterine fibroids?
Do you have piercing or stabbing menstrual cramps?
Do you have dark spots in your eyes?
Have you been diagnosed with any vascular abnormality or blood clotting disorder?
Are you prone to emotional depression?
Are you prone to anger and/or rage?
Do you become irritable premenstrually?
Do you feel bloated or irritable around ovulation?
Does it feel as if your ovulation lasts longer than it should?
Are your breasts sensitive/sore at ovulation?
Do you experience nipple pain or discharge from your nipples?
Do you have a lot of pre-menstrual breast distension or pain?
Do you become bloated pre-menstrually?
Are your pupils usually dilated and large?
Do you have difficulty falling asleep at night?
Do you experience heartburn or wake up with a bitter taste in your mouth
Are your menses painful?
Do you feel your menstrual cramps in the external genital area?
Is your menstrual blood thick and dark, or purplish in color?
Do you wake up early in the morning and have trouble getting back to sleep?
Do you have heart palpitations, especially when anxious?
□ Do you have nightmares?
Do you seem low in spirit or lacking vitality?
Are you prone to agitation or extreme restlessness?
Do you fidget?
Do you sweat excessively, especially on your chest?
Are your mouth and throat usually dry?
Are you often thirsty for cold drinks?
Do you often feel warmer than those around you?
Do you wake up sweating or have hot flashes?
Do you breakout with red acne, especially pre-menstrually?
Do you have a short menstrual cycle?
Do you have vaginal irritation?
Do you feel tired and sluggish after a meal?
Do you have fibrocytic breasts?
Do you have cystic or pustular acne?
Do you have urgent, bright, or foul-smelling stools?
Does your menstrual blood contain stringy tissue or mucus?
Are you prone to yeast infections and vaginal itching?
Are you overweight?
Do you have a wet, slimy tongue?
Does your body feel like a barometer? Can you sense when it will rain?
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Fertility Information
# of IVF procedures
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# of IUI procedures
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# of pregnancies
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#of miscarriages
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# of live birth
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Has a physician diagnosed a difficulty with fertility due to:
Female Factor
Male Factor
Unexplained
Other
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If Other Elaborate...
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Please check which services you would be interested in:
Chinese herbal medicine
Therapeutic massage
Tai chi
Qi gong health exercises
Relaxation techniques
Nutritional consultation
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In order to maintain the integrity of our practice, Golden Valley Acupuncture Center must request that all cancellations be made prior to within 24 hours of your appointment. Failure to provide at least a 24 hour notice or failure to show for an appointment will result in your account being charged for the full price of the visit.*
THANK YOU FOR YOUR UNDERSTANDING.
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