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Microsoft word - npi_women_form.doc

596 Broadway Suite 302, NY, New York 10012 This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. If you have questions, please ask. Thank you. Personal Information
Name ___________________________________________ Date _____________________________ Home Address _________________________________________________________________________ City _________________________ State ________________________ Zip _______________________ Home Phone _____________________ Email ______________________ Work Phone _______________ Cell Phone _____________________ What is the best way of contacting you? _____________________ Occupation _____________________________ Person Responsible for your account _________________ Emergency Contact : Name _____________________________ Phone _____________________________ Who should we thank for referring you to this office? ______________________________________________ Sex : □ Male □ Female Height ______ Weight _______ Birth date ___________ Age _________ Marital Status : Married Single Divorced Widowed Have you received acupuncture therapy before? □ Yes □ No When? _______________________________ With whom? ______________________________ Please indicate any significant illnesses you or a blood relative (Grandparent, parent or sibling) have had: List any medications and supplements you are currently taking: (Continue on back if necessary.) Check the Box if any of the following statements are true:
□ I have known allergies □ I am taking Coumadin/warfarin □ I have a pacemaker □ I am taking lithium ( Eskalith, Lithobid, Lithonate, Lithotabs) Any allergies, food sensitivities or food cravings/restrictions (i.e. vegetarian, vegan, Kosher) that you have: ____________________________________________________________________________________ ____________________________________________________________________________________ Please indicate any other important information: ____________________________________________________________________________________ ____________________________________________________________________________________ List any accidents, surgeries, or hospitalizations: (include dates) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Please indicate the use and frequency of the following:
How do you FEEL about the following areas of your life?:
Please check the appropriate boxes and indicate any problems you may be experiencing. What is your average stress level? (1 is lowest, 10 highest) What is your average energy level? (1 is lowest, 10 highest) please circle : 1 2 3 4 5 6 7 8 9 10 What time of the day is your energy typically at it’s best? _______________ it’s worst?___________________ # of hours you get sleep per night: ? _____ time goto bed: ? __________ Do you sleep well? Y / N ( if no, describe) Difficulty: Falling asleep / staying asleep / waking up What are the main health problems for which your are seeking treatment? Please list in order of importance. 1.____________________________________ Date of onset: _____________________ 2.____________________________________ Date of onset: _____________________ 3.____________________________________ Date of onset: _____________________ 4.____________________________________ Date of onset: _____________________ What other forms of treatment have you sought? Are you under a physician’s care for any of your health concerns? ( please describe if appropriate): Please name your Physician and his/her contact information:
Symptom Survey
The following is a list of symptoms that you CURRENTLY mayexperience. Please indicate as follows: No mark ( ) =Never experience Check mark (√) = sometimes experience Plus sign ( +) = frequently experience For Women
Age of 1st period (menarche) ________ Are you pregnant? □ Yes □ No #of pregnancies_______ Age of last period (menopause) _________ # of live births ___ # of Abortions ___ # of Miscarriages ____ Date of last: Gynecologic exam _______ Pap Smear ________ Mammogram ___________ Bone Density Scan ____________ # of days between periods ________ # of days of flow ________________ Average number of tampons/pads you use per day: 1st day ____ 2nd day ____ 3rd day ____ 4th day ____ + days ___ Color of menstrual Blood: ________________________________________________________ □Pale/light red □dark red □Red □dark red/brown □Bright red □clots Amount of menstrual Blood: ________________________________________________________ □Light □Heavy □Even throughout □Starts /stops Have you been diagnosed with: □ Fibroids □ Fibrocystic Breasts □ Endometriosis □ Ovarian Cysts □ PID □ Hysterectomy □ Beast/Uterine/Ovarian Cancer □ Other ______________________ Location of Pain: □ Lower abdomen □ Lower back □ Thighs □ Other:___________________ Other Symptoms related to menses: (please describe) (Please indicate before, during or after menses) Bearing down sensation __________________ Frequently
Occasionally
Frequently
Occasionally
Is your Fertility an issue? (please describe): What (if any) treatments have you sought for fertility? Success? What form of birth control are you currently using? _____________________ How long? _________ What other forms of birth control have you used in the past? Sexually Transmitted Diseases: □Gonorrhea □Syphilis □AIDS □HPV □Chlamydia □Herpes Do you experience any other sexual difficulties? ( please describe)
Thank you for taking the time to answer these questions, we appreciate your time & efforts.
I certify that the information I have provided above is correct and accurate to the best of my knowledge.

_____________________________
In the space provided below, please feel free to write down any other signs or symptoms and any other information
you would like to mention that have not been covered in the previous pages

Source: http://www.sahmacupuncture.com/NPI_WOMEN_form.pdf

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