Forms

Client Intake Form

Indigo Sun Acupuncture w 631 Birch Street, Unit D, Windsor, CO 80550 w (970) 213-6331

Date: __________________

Name: _______________________________________________________________________________________

First Middle Last

Address: _____________________________________________________________________________________

Street City State Zip

Home Ph #: _____________ Business/Cell #: _____________ Email: ____________________________________

Age: ______ Date of Birth: _____ /_____ /______ Gender: M F Height: ______ Weight: _______

MM DD YY

Marital Status: S M D W Number of Children: _____ Occupation: _________________________________

Employer:____________________________________________________________________________________

Primary Care Physician: ________________________________________________________________________

Physician's Ph #: ____________________________ Last Physical Exam Date: ____________________________

Emergency Contact: ____________________________________________________________________________

NameRelationPhone #

Referred by: __________________________________________________________________________________

Heath Insurance (complete ONLY if you are covered for acupuncture services through Blue Cross Blue Shield)

Insurance Company: ______________________________________________ Provider #: ___________________

Member ID #: ______________________ Group #: _____________________

Primary Cardholder's Name: _____________________________________ Date of Birth: ___________________

Person Medical History (surgeries, hospitalizations, illness, diseases, accidents and dates):

____________________________________________________________________________________________

Contagious diseases:

_____ None _____ HPV _____ Herpes _____MRSA _____AIDS _____ Hepatitis (A,B,C,D)

_____ STDs _____Other __________________________________________________________________

Allergies: ___________________________________________________________________________________

____________________________________________________________________________________________

Medications & Supplements (herbs & vitamins) you are taking or have taken in recent past:

____________________________________________________________________________________________

Family Medical History (parents, grandparents, sibilings, children):

____ alcoholism _____ allergies _____ arthritis _____ asthma _____stroke

____ drug abuse _____ epilepsy _____ eye disease _____ heart disease _____TB

____ kidney disease _____ liver disease _____ mental health _____ sinus problems

____ spine problems _____ diabetes _____ high/low blood pressure

Age Parents Died: _____ Mother _____ Father

Present Illness:

What is your chief complaint?____________________________________________________________________

____________________________________________________________________________________________

Date this condition began? _________________

How did this condition begin?______________________________________________________________

____________________________________________________________________________________________

What treatment have you received for this condition?__________________________________________________

____________________________________________________________________________________________

Effectiveness of treatment received?_______________________________________________________________

____________________________________________________________________________________________

What makes it better?__________________________________________________________________________

What makes it worse?__________________________________________________________________________

Lifestyle Habits:

____black tea ____coffee ____chewing tobacco ____ alcohol ____soft drinks

____cigarettes ____sugar ____ recreational drugs ____ salt ____other ______________

Exercise:

____ never ____occasional ____ moderate ____ heavy

Type of Exercise: ______________________________________________________________________________

Emotions:

____happy (excess/deficient) ____worry ____anxious/restless ____controlling ____fear

____over thinking ____stubborn ____sadness/grief ____cry easily ____aloof

____poor willpower ____reckless ____angry/irritable ____depression ____other ________

Energy:

____normal ____low ____excess ____low after eating ____low in afternoon

____more energy at night ____variable ____other___________________________________________________

Weight:

____normal ____underweight ____overweight

____recent gain (how much?____ ) ____recent loss (how much?____ )

Appetite:

____variable ____poor ____good ____excessive ____hungers rapidly ____loss of taste

____other ____________________________________________________________________________________

Diet (describe a typical meal):

breakfast: _____________________________________________________________________________________

lunch: ________________________________________________________________________________________

dinner: _______________________________________________________________________________________

cravings? _____________________________________________________________________________________

Do you eat 3 meals a day?______ Do you eat a regular hours?______ Do you eat late at night?______

Digestion:

____normal ____heartburn ____belching/burping ____gas ____bitter taste

____nausea/vomit ____nervous stomach ____bloating ____bad breath ____gallstones

____stomach noises ____hiccups ____indigestion ____full feeling or distention

____abdominal pain/cramps ____difficulty digesting fatty/oily foods ____food doesn't descend

____other ____________________________________________________________________________________

Bowels:

____ normal ____loose stool ____ black stool ____ burning anus ____ diarrhea

____ constipation ____hemorrhoids ____colon problems ____ hard stool ____ anus itch

____ blood in stool ____stool w bad smell ____ pain/cramps ____ small stool amount

____laxative use ____mucous in stool ____intestinal worms ____ undigested food in stool

____alternating constipation & diarrhea/loose stool ____other___________________________

Urination: (4-6x per day is normal)

____normal ____burning ____dribbling after urination ____bladder infections ____urgency

____frequent ____blood ____bladder infections ____pus/infections ____profuse

____cloudy ____strong smell ____abnormal color ____night time ____painful

____scanty ____kidney stones ____other_________________________

Body Temperature:

____normal ____warm natured ____feel warmer in late afternoon & night

____cold natured ____warm palms ____cold hands & feet ____warm soles

____cold lower body ____warm upper body ____flushed face ____alternating chills & fever

____other ____________________________________________________________________________________

Perspiration:

____normal ____profuse ____small amounts ____head ____chest ____palms ____feet

____bad smell ____oily ____night sweats ____hot flashes ____without exercise

____other____________________________________________________________________________________

Thirst:

____normal____less than normal ____excessive ____prefer hot drink ____prefer cold drink

____increased thirst at night ____thirsty but do not drink ____other __________________________________

Sleep:

____normal ____vivid dreams ____difficulty falling asleep ____difficulty going back to sleep

____restless ____sleep too much ____awake tired in morning ____wakes easily ___nightmares

____other_____________________________________________________________________________________

Headaches/Dizziness:

____headaches ____dizziness ____poor balance ____motion sickness ____heavy headed feeling

____migraines ____vertigo ____poor memory ____fainting ____dizzy w changes in position

____other _____________________________________________________________________________________

Skin:

____normal ____eczema ____boils ____body odor ____oily ____slow to heal ____ulcers

____moles ____clammy ____dry ____itching ____warts ____bruise easily ____hives

____acne ____yellow skin ____rashes ____other _________________________________________

Hair:

____normal ____oily ____dandruff ____falling out ____dry/brittle ____prematurely grey

____other______________________________________________________________________________________

Nails:

_____normal ____spots ____grow slowly ____grow rapidly ____brittle/break easily

_____purple ____soft ____pale ____ridged/lines ____other______________________________

Eyes:

_____normal _____eyelids swollen _____blurry vision ____red _____need glasses/contacts

_____tearing _____inflammation _____glaucoma ____dry _____spot/lines in vision

_____itching _____poor night vision _____failing vision ____pain _____pale under eyelids

_____twitching _____stymy history _____cataracts ____strain _____macular degeneration

_____blinking _____color blindness _____light sensitivity ____other ______________________________

Ears:

____normal _____discharges ____poor hearing ____ear aches/pain _____ringing (high/low pitch)

____itching _____infections ____whooshing sound ____other_________________________________

Nose:

____normal ____allergies ____sneezing ____environmental ____congestion ____overly dry

____rhinitis ____sinusitis ____bleeding ____post nasal drip ____nasal sores ____nasal polyps

____mucous ____loss of smell sensitivity ____structural issues ____other ______________________

Mouth & Throat:

____normal ____difficulty swallowing ____grind teeth ____mouth/tongue sores ____dry/cracked lips

____drooling ____lump in throat feeling ____tonsillitis ____teeth problems ____gum problems

_____TMJ ____thyroid problems ____hoarseness ____frequent sore throat ____swollen glands

_____dry ____other________________________________________________________________________

Respiratory:

____normal ____difficult inhalation ____difficult exhalation ____dry cough ____frequent sighing

____asthma ____excess coughing ____shortness of breath ____chest pain ____cough with phlegm

____bronchitis ____frequent colds ____cough with blood ____lung cancer ____emphysema/COPD

____on oxygen ____tightness in chest ____difficult breathing when lying down ____other___________

Cardiovascular / Circulation:

____normal ____palpitations ____high cholesterol ____low cholesterol ____numb/tingling limbs

____murmur ____bleed easily ____bleeding disorder ___varicose veins ____diagnosed heart problem

____anemia ____blood clots ____slow heart beat ____high blood pressure ____low blood pressure

____chest pain ____bruise easily ____purple hands/feet ____irregular heart beat

____swelling (ankles, hands, face) ____other_______________________________________________________

Pain:

Where are you feeling pain in your body: _______________________________________________________________

________________________________________________________________________________________________

What makes the pain worse? _________________________________________________________________________

_________________________________________________________________________________________________

What makes the pain better? _________________________________________________________________________

_________________________________________________________________________________________________

Any other problems you would like to discuss? ___________________________________________________________

_________________________________________________________________________________________________

FOR MALES ONLY:

____reduced sex drive _____impotence ____genital pain ____dribbling after urination

____sperm problems _____hernia ____prostate problems ____pain/burning with urination

____seminal emissions _____discharges ____premature ejaculation ____other___________________

Men, you have completed this form. Thank you!

FOR FEMALES ONLY:

Are you pregnant? ____Yes ____No

If yes, what is the approximate date of conception? _________________________________________

What method of birth control do you currently use? _________________________________________

What method of birth control have you used in the past? _____________________________________

Do you have regular PAP tests? ____Yes ____No

Do you have regular breast exams? ____Yes ____No

Do you have breast implants? ____Yes ____No

Do you have excess facial/body hair? ____Yes ____No

Do you have a reduced sex drive? ____Yes ____No

Menstrual Cycle:

Age started? _______Days of flow? _______Age stopped? _______

How many days from the beginning of your peiod to the beginning of the next one? ________

Check all that apply:

____irregular ____heavy flow ____scanty flow ____dark flow color (dark red, purple)

____clotting ____no menses ____water retention ____ light flow color (light red, brownish)

____sighing ____pain/cramps ____skin eruptions ____lump in throat feeling

____backache ____breast lumps ____abdominal bloating ____painful/tender breasts

____mood swings/changes ____constipation or diarrhea ____other_______________________

Discharges:

____thick ____white ____ yellow ____clear ____ itching ____yeast infections

____blood ____none ____bad odor ____ other____________________________________________

Pregnancies:

Total number?______ Number of children?______

Number of abortions?______ Number of miscarriages? ______

Any preganancy or childbirth complications? (explain) _________________________________________________

____________________________________________________________________________________________

Menopause:

____hot flashes ____dizziness ____night sweats ____anxiety ____memory problems

____fatigue ____poor sleep ____ palpitations ____tinnitus ____mental restlessnes

____backache ____feel cold ____cold feet ____irritable ____frequent urination

____dry mouth ____N/A ____ other _________________________________________________

Any other gynecological concerns? __________________________________________________________________

Women, you have completed this form. Thank you!

Informed Consent

I hereby request and consent (or provide consent for the patient named below for whom I am legally

responsible) to the performance of acupuncture and other procedures within the scope of practice of

Traditional Chinese Medicine by the acupuncturist named below and/or other licensed acupuncturists who

may in the future treat me while employed by, working or associated with, or serving as back-up for the

acupuncturist named below, including those working at the office/clinic listed below, whether signatories

to this form or not.

I have had an opportunity to discuss with the acupuncturist named below (and/or with other office/clinic

personnel) the nature and purpose of acupuncture and adjunct therapies (tui na, auriculotherapy,

moxibustion, cupping, bleeding, gwa sha, dietary and lifestyle instruction).

I understand that the therapies provided through Traditional Chinese Medicine are not to be considered a

substitute for Western Medicine nor are these therapies be construed by the client to be a diagnosis or

treatment of any disease or injury.

I understand and am informed that, as in the practice of medicine, in the practice of acupuncture and

adjunct therapies, there are some risks to treatment, including but not limited to nausea, light headedness,

fainting, bruising, hematoma, nerve damage, skin irritation or burn, a punctured lung or organ, and

infection. I do not expect the acupuncturist to be able to anticipate and explain all risks and complications,

and wish to rely on the acupuncturist to exercise judgment during the course of the procedure which the

acupuncturist feels at the time, based upon the facts then known, is in my best interests.

I HAVE READ OR HAVE HAD READ TO ME THE ABOVE CONSENT. I HAVE ALSO HAD AN OPPORTUNITY

TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE TO THE ABOVE NAMED

PROCEDURES. I INTEND THIS CONSENT FORM TO COVER THE ENTIRE COURSE OF TREATMENT OF

MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION AND FOR ANY FUTURE CONDITION(S)

FOR WHICH I SEEK TREATMENT.

To be completed by the patient or patient's representative

(if patient is a minor or physically/legally incapacitated)

X______________________________________________

Patient's Name--PRINT

X_____________________________________________

Patient / Representative's Signature

X ____________________________________________

Date Signed

INDIGO SUN ACUPUNCTURE

Ellen B. Williams, L. Ac., Dipl. Ac.

631 Birch Street, Unit D

Windsor, CO 80550

(970) 213-6331

Fax (970) 800-3480