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Laura Deloatch, L.Ac, Dipl. OM
Anupa Wellness
New Patient Forms

Click Here for the New Patient Form.


This is a CONFIDENTIAL questionnaire.  This will help me determine the best course of treatment.  If you have any questions please ask.

Name_____________________________________Date of Birth:_______________

Address:______________________________________________________________

City:____________________________________Zip:_________________________

Phone Number:_______________________ Cell Number:_____________________

Email Address:________________________________________________________

Occupation:___________________________________________________________

Emergency Contact:_____________________ Number:_______________________

Marital Status:_________________ Number of Children:__________________

Who may I thank for referring you to my office?

______________________________________________________________________


Have you received acupuncture before?__________Last Treatment__________

What is your reason for seeking treatment? ____________________________________________________________________________________________________________________________________________________________________________________________________________________

What other treatment therapies have you sought for this?

________________________________________________________________________________________________________________________________________________

Please list any medications, OTC medications, supplements, vitamins, or herbs you are currently taking:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have a Latex allergy?_____________________

Do you have any allergies to medications? ____________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Do you have any food allergies or sensitivities? ____________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list any major illnesses, surgeries, accidents with dates:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Please indicate any major illnesses/conditions you or a blood relative (parent, sibling, grandparent) have had:

Illness/Condition:                 Who?

Arthritis:______________________________________________________________

Asthma:_________________________________________________________________

Cancer:_________________________________________________________________

Diabetes:_______________________________________________________________

Emotional Disorders:____________________________________________________

Heart Disease:__________________________________________________________

Hepatitis_______________________________________________________________

High Blood Pressure: ___________________________________________________

HIV/AIDS:_______________________________________________________________

Kidney Disease:_________________________________________________________

Seizures/Tremors:_______________________________________________________

Sexually Transmitted Infections:________________________________________

Stroke:_________________________________________________________________

Thyroid Disorder:_______________________________________________________

Tuberculosis: __________________________________________________________

 

Musculoskeletal: please list any problems or pain that you are experiencing: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 


Diet:

How many times a day do you eat?________________________________________

After you eat are you satisfied or still feel hungry?___________________
Do you feel tired after eating a meal?__________________________________

Are there any foods you exclude from your diet?_________________________ ________________________________________________________________________________________________________________________________________________

________________________________________________________________________

What foods are in a typical Breakfast:___________________________________________________________________________________________________________________________________________________________________________________________________________

Lunch:_____________________________________________________________________________________________________________________________________________________________________________________________________________

Dinner:_________________________________________________________________

________________________________________________________________________________________________________________________________________________

Do you drink alcohol? ___________   If yes, how frequent? ______________

Do you smoke? __________ If yes, how many per day?  ____________________

Do you drink coffee?__________If yes, how many cups per day?____________

Do you take recreational drugs?____________If yes, what and frequency? ________________________________________________________________________

Do you drink soda?_______________If yes, how often?_____________________

How often do you eat out? ______________________________________________

How many much water do you drink per day?_______________________________

Do you prefer your water:

Hot, cold, iced or room temperature?____________________________________


Sleep:

What time do you go to bed?___________ What time do you wake?___________

Average number of hours of sleep?_______________________________________

Do you feel rested when you wake?_______________________________________

Do you have problems falling asleep? ________________________________________________________________________

Do you have problems staying asleep? ________________________________________________________________________


Female Reproductive:

Are you pregnant? _________ if yes, how many weeks along? _____________                  

if no, are you trying to get pregnant?_________

# of pregnancies______# of live births______# of miscarriages _____# of abortions_____

Age of first Menses:_______________

Please CIRCLE any that you are experiencing or have experienced:

Ovarian cysts Fibroids Fibrocystic Breast

Painful Periods HPV Vaginal Discharge

Endometriosis PID Breast Lumps/Tenderness

Irregular Cycles Heavy Flow Light/Scanty Flow

Bleeding between Cycles   Absence of Flow

Length of Menses:______________________________________________________

Length of Menstruation cycle?___________________________________________

Color of flow: ________________________________________________________

Are there clots?__________  If yes, what size?(dime, nickel, quarter)

_______________________________________________________________________

Do you experience PMS symptoms?______________If yes, please describe: ________________________________________________________________________________________________________________________________________________



Male Reproductive:

Please CIRCLE any that you experience or have experienced in the past.

Sexual Difficulties Prostate Problems

Penile Discharge Erectile Dysfunction

Testicular Pain/Swelling


Symptoms Survey (for everyone):

Please mark the following symptoms that you experience:

(   ) recent use of antibiotics: Name of medicine:______________________

for what reason?________________________________________________________

(   ) high cholesterol                  (   ) angina

(   ) high blood pressure           (   ) chest pain

(   ) shortness of breath            (   ) fainting

(   ) irregular heart beat/palpitations

(   ) dizziness/vertigo

(   ) nightmares

(   ) vivid dreams

(   ) insomnia                              (   ) laughing for no reason

(   ) night sweating

(   ) hot flashes

(   ) frequent colds/flu             (   ) excessive sadness

(   ) bronchitis                          (   ) asthma

(   ) hay fever                            (   ) allergies

(   ) acne                                     (   ) rashes

(   ) decreased sense of smell

(   ) intolerance to weather      (   ) chills and fever             

(   ) low back pain/weakness

(   ) sciatic pain                     (   ) edema

(   ) knee pain/weakness       (   ) decreased hearing

(   ) urinary problems          (   ) excessive fear

(   ) kidney stones                 (   ) painful/difficult urination

(   ) numbness/tingling          (   ) blood in urine

(   ) soft/brittle nails              (   ) dry/itchy/red eyes

(   ) cold hands/feet               (   ) decreased vision

(   ) floaters in vision

(   ) spasms/twitching of muscles                                   

(   ) headache                         (   ) easily angered/agitated

(   ) migraine

(   ) mental restlessness          (   ) ear ringing/tinnitus

(   ) fatigue                              (   ) sudden weight loss/gain

(   ) lack of appetite               (   ) acid reflux/heart burn

(   ) excessive appetite            (   ) burping/belching

(   ) nausea                              (   ) abdominal pain/cramping

(   ) vomiting                           (   ) hemorrhoids                  

(   ) diarrhea/loose stools       (   ) bruising

(   ) dark tarry stool               (   ) hair loss       

(   ) light colored stool           (   ) blood in stool

(   ) IBS

(   ) excessive gas                   (   ) colitis or diverticulitis

(   ) constipation

(   ) gallstones                        (   ) excessive worry

(   ) difficulty digesting oily/greasy foods

(   ) difficulty making decisions