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.
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:
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
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 __________________
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
New Tests and Test Updates In our continuing effort to provide you with the highest quality toxicology laboratory services available, we have compiledimportant changes regarding a number of tests we perform. Listed below are the types of changes that may be included inthis notification, effective Friday, June 17, 2011 New Tests - Tests recently added to the NMS Labs test menu. New Tests ar
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