General Intake Form NameField is required!Field is required!AgeField is required!Field is required!Select a dateField is required!Field is required!Home AddressField is required!Field is required!CityField is required!Field is required!StateField is required!Field is required!ZipField is required!Field is required!Home PhoneField is required!Field is required!Work PhoneField is required!Field is required!E-mailField is required!Field is required!BirthdateField is required!Field is required!If under 18, person responsible for your accountNameField is required!Field is required!Emergency ContactNameField is required!Field is required!Contact PhoneField is required!Field is required!OccupationField is required!Field is required!GenderField is required!Field is required!HeightField is required!Field is required!WeightField is required!Field is required!Whom should we thank for referring you to our office?Field is required!Field is required!Have you had acupuncture therapy before?YesNoField is required!Field is required!With Whom?Field is required!Field is required!Please indicate any significant illnesses you or a blood relative (grandparent, parent, or sibling) have had:(marking “yes” does not make you ineligible for treatment, however, it may restrict some treatment modalities):CancerYouYour RelativeField is required!Field is required!HepatitisYouYour RelativeField is required!Field is required!High Blood Pressure YouYour RelativeField is required!Field is required!Rheumatic FeverYouYour RelativeField is required!Field is required!Infectious DiseasesYouYour RelativeField is required!Field is required!DiabetesYouYour RelativeField is required!Field is required!Heart DiseaseYouYour RelativeField is required!Field is required!SeizuresYouYour RelativeField is required!Field is required!Emotional DisorderYouYour RelativeField is required!Field is required!TuberculosisYouYour RelativeField is required!Field is required!Sexually Transmitted DiseasesGonorrheaSyphilisHPVChlamydiaHerpesField is required!Field is required!DatesField is required!Field is required!Other ConditionsHIV/AIDSPacemakerBlood-Thinning MedsPregnancyField is required!Field is required!DatesField is required!Field is required!List any medications and supplements you are currently taking: (Continue on back if necessary)MedicineField is required!Field is required!DosageField is required!Field is required!ReasonField is required!Field is required!How LongField is required!Field is required!Prescribed byField is required!Field is required!Date of Last CheckupField is required!Field is required!Please indicate the use and frequency of the following:Coffee/Black TeaYesNoField is required!Field is required!How MuchField is required!Field is required!Soda PopYesNoField is required!Field is required!How MuchField is required!Field is required!Recreational DrugsYesNoField is required!Field is required!How MuchField is required!Field is required!TobaccoYesNoField is required!Field is required!How MuchField is required!Field is required!AlcoholYesNoField is required!Field is required!How MuchField is required!Field is required!Water IntakeYesNoField is required!Field is required!How MuchField is required!Field is required!Age of first period (menarche)Field is required!Field is required!Are you pregnantYesNoField is required!Field is required!# of pregnanciesField is required!Field is required!Age of last period (menopause)Field is required!Field is required!# of live births:Field is required!Field is required!# of abortions:Field is required!Field is required!# of miscarriages:Field is required!Field is required!Number of days between periodsField is required!Field is required!Date of last: OB/GYN exam:Field is required!Field is required!PAP Smear:Field is required!Field is required!Number of days of flowField is required!Field is required!MammogramField is required!Field is required! Bone Density Scan:Field is required!Field is required!Color of flowField is required!Field is required!ResultsField is required!Field is required!Clots?YesNoField is required!Field is required!ColorField is required!Field is required!# of pads you use per day:# of pads you use per day:Field is required!Field is required!1 st dayField is required!Field is required!2 ND dayField is required!Field is required!3 RD dayField is required!Field is required!4 th dayField is required!Field is required!+daysField is required!Field is required!Have you been diagnosed with:Fibroids Fibrocystic breasts Endometriosis Ovarian CystsPID OtherField is required!Field is required!Location of pain: Lower abdomenLower backThighsOtherField is required!Field is required!Nature of pain: (Please indicate before, during, or after menses)CrampingField is required!Field is required!StabbingField is required!Field is required!BurningField is required!Field is required!AchingField is required!Field is required!DullField is required!Field is required!BloatingField is required!Field is required!ConsistentField is required!Field is required!IntermittentField is required!Field is required!Bearing Down SensationField is required!Field is required!Other symptoms related to menses: Vaginal DrynessDischargeHeadacheNauseaConstipationDiarrheaSwollen breastsMood SwingsRavenous AppetitePoor AppetiteHot FlashesNight Sweats Increased LibidoDecreased Libido InsomniaField is required!Field is required!Have you ever been diagnosed with: fibroidsfibrocystic breastsendometriosisovarian cystsPID polycystic ovary syndromeSTDField is required!Field is required!Date of last prostate check upField is required!Field is required!PSA ResultsField is required!Field is required!Manual Prostate exam resultsField is required!Field is required!Lab Results:Field is required!Field is required!Frequency of urination: daytime Field is required!Field is required!NighttimeField is required!Field is required! Color of urineField is required!Field is required!OdorField is required!Field is required!Symptoms related to prostate:Prostate problemsDelayed StreamDribblingIncontinenceRetention of UrineRectal Dysfunction Increased LibidoDecreased Libido Premature EjaculationImpotenceBack PainGroin Pain Testicular PainField is required!Field is required!OtherField is required!Field is required!Date of last prostate check upField is required!Field is required!PSA ResultsField is required!Field is required!Manual Prostate exam resultsField is required!Field is required!Lab Results:Field is required!Field is required!The following is a list of symptoms that you may or may not ever experience.lack of appetiteNever experiencesometimes experienceFrequently experienceField is required!Field is required!skin problemsNever experiencesometimes experienceFrequently experienceField is required!Field is required!excessive appetiteNever experiencesometimes experienceFrequently experienceField is required!Field is required! feeling of claustrophobiaNever experiencesometimes experienceFrequently experienceField is required!Field is required!loose stool or diarrheaNever experiencesometimes experienceFrequently experienceField is required!Field is required!bronchitisNever experiencesometimes experienceFrequently experienceField is required!Field is required! poor digestion/indigestion/vomitingNever experiencesometimes experienceFrequently experienceField is required!Field is required!colitis or diverticulitisNever experiencesometimes experienceFrequently experienceField is required!Field is required!belching, burpingNever experiencesometimes experienceFrequently experienceField is required!Field is required!constipationNever experiencesometimes experienceFrequently experienceField is required!Field is required!heartburn/refluxNever experiencesometimes experienceFrequently experienceField is required!Field is required!hemorrhoidsNever experiencesometimes experienceFrequently experienceField is required!Field is required!skin problemsNever experiencesometimes experienceFrequently experienceField is required!Field is required!feeling of claustrophobiaNever experiencesometimes experienceFrequently experienceField is required!Field is required!feeling food retention in the stomachNever experiencesometimes experienceFrequently experienceField is required!Field is required!recent use of antibioticsNever experiencesometimes experienceFrequently experienceField is required!Field is required!tendency to become obsessiveNever experiencesometimes experienceFrequently experienceField is required!Field is required!eye problemsNever experiencesometimes experienceFrequently experienceField is required!Field is required!insomnia, difficulty sleepingNever experiencesometimes experienceFrequently experienceField is required!Field is required!jaundice (yellowish eyes or skin)Never experiencesometimes experienceFrequently experienceField is required!Field is required!heart palpitationsNever experiencesometimes experienceFrequently experienceField is required!Field is required!difficulty digesting oily foodsNever experiencesometimes experienceFrequently experienceField is required!Field is required!cold hands and feetNever experiencesometimes experienceFrequently experienceField is required!Field is required!gall stones Never experiencesometimes experienceFrequently experienceField is required!Field is required!nightmares Never experiencesometimes experienceFrequently experienceField is required!Field is required!light colored stoolNever experiencesometimes experienceFrequently experienceField is required!Field is required!mentally restlessNever experiencesometimes experienceFrequently experienceField is required!Field is required!laughing for no apparent reasonNever experiencesometimes experienceFrequently experienceField is required!Field is required!angina painsNever experiencesometimes experienceFrequently experienceField is required!Field is required!abdominal pain Never experiencesometimes experienceFrequently experienceField is required!Field is required!chest painNever experiencesometimes experienceFrequently experienceField is required!Field is required!sciatic painNever experiencesometimes experienceFrequently experienceField is required!Field is required!headaches Never experiencesometimes experienceFrequently experienceField is required!Field is required!pain or coldness in the genital areaNever experiencesometimes experienceFrequently experienceField is required!Field is required!coughNever experiencesometimes experienceFrequently experienceField is required!Field is required!shortness of breathNever experiencesometimes experienceFrequently experienceField is required!Field is required! decreased sense of smellNever experiencesometimes experienceFrequently experienceField is required!Field is required!nasal problemsNever experiencesometimes experienceFrequently experienceField is required!Field is required!skin problems Never experiencesometimes experienceFrequently experienceField is required!Field is required! bronchitisNever experiencesometimes experienceFrequently experienceField is required!Field is required! soft or brittle nailsNever experiencesometimes experienceFrequently experienceField is required!Field is required!easily angered or agitatedNever experiencesometimes experienceFrequently experienceField is required!Field is required!difficulty in making plans/decisionsNever experiencesometimes experienceFrequently experienceField is required!Field is required!spasms or twitching of musclesNever experiencesometimes experienceFrequently experienceField is required!Field is required!low back pain Never experiencesometimes experienceFrequently experienceField is required!Field is required!knee problems Never experiencesometimes experienceFrequently experienceField is required!Field is required!hearing impairmentNever experiencesometimes experienceFrequently experienceField is required!Field is required!ears ringingNever experiencesometimes experienceFrequently experienceField is required!Field is required! kidney stones Never experiencesometimes experienceFrequently experienceField is required!Field is required!decreased sex driveNever experiencesometimes experienceFrequently experienceField is required!Field is required!hair lossNever experiencesometimes experienceFrequently experienceField is required!Field is required!urinary problemsNever experiencesometimes experienceFrequently experienceField is required!Field is required!fatigueNever experiencesometimes experienceFrequently experienceField is required!Field is required!edema Never experiencesometimes experienceFrequently experienceField is required!Field is required!blood in stool Never experiencesometimes experienceFrequently experienceField is required!Field is required!black tarry stoolNever experiencesometimes experienceFrequently experienceField is required!Field is required!easily bruised Never experiencesometimes experienceFrequently experienceField is required!Field is required!difficulty in stopping bleedingNever experiencesometimes experienceFrequently experienceField is required!Field is required!asthmaNever experiencesometimes experienceFrequently experienceField is required!Field is required!tendency to catch colds easilyNever experiencesometimes experienceFrequently experienceField is required!Field is required!intolerance to weather changesNever experiencesometimes experienceFrequently experienceField is required!Field is required!allergiesNever experiencesometimes experienceFrequently experienceField is required!Field is required! hay feverNever experiencesometimes experienceFrequently experienceField is required!Field is required!dizzinessNever experiencesometimes experienceFrequently experienceField is required!Field is required!tendency to faint easilyNever experiencesometimes experienceFrequently experienceField is required!Field is required!high cholesterol levelsNever experiencesometimes experienceFrequently experienceField is required!Field is required! sudden weight lossNever experiencesometimes experienceFrequently experienceField is required!Field is required!How do you FEEL about the following areas of your life? Please check the appropriate boxes and indicate any problems you may be experiencing.Significant OtherGreatGoodFairPoorBadField is required!Field is required!Your Comments...Field is required!Field is required!FamilyGreatGoodFairPoorBadField is required!Field is required!Your Comments...Field is required!Field is required!DietGreatGoodFairPoorBadField is required!Field is required!Your Comments...Field is required!Field is required!SexGreatGoodFairPoorBadField is required!Field is required!Your Comments...Field is required!Field is required!SelfGreatGoodFairPoorBadField is required!Field is required!Your Comments...Field is required!Field is required!WorkGreatGoodFairPoorBadField is required!Field is required!Your Comments...Field is required!Field is required!ExerciseGreatGoodFairPoorBadField is required!Field is required!Your Comments...Field is required!Field is required!SpiritualityGreatGoodFairPoorBadField is required!Field is required!Your Comments...Field is required!Field is required!What are the main health problems for which you are seeking treatment?Main health problems...Field is required!Field is required!How long have you had this condition?Field is required!Field is required!What other forms of treatment have you sought?Field is required!Field is required!What helps your condition?Field is required!Field is required!What aggravates your condition?Field is required!Field is required!List any other health problems you now have.Field is required!Field is required!List any allergies, food sensitivities or food cravings that you haveField is required!Field is required!Please list any accidents, surgeries, hospitalizations or other major health incidents in your life, including dates:Field is required!Field is required!Upload your documents...Field is required!Field is required!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.PRINT NAME:Field is required!Field is required!Select a dateField is required!Field is required!Signature:Field is required!Field is required!*We do understand that unforeseen circumstances arise, and for that we will not charge you the first time this situation occurs.Submit
