Patient Information Form We are currently working on updates to our online form. In the mean time, please use the printable PDF form: click here. This form requires javascript to operate properly. Either turn on javascript or use a browser with javascript to continue. [pdf-embedder url="https://meridianacupuncture.com/wp-content/uploads/2015/09/Patient_Information_Form_Print_Template_y15m09d18.pdf" width="100%"] . PATIENT INFORMATION First Name: Middle Inital: Last Name: Age: Gender: Date of Birth: Home Address (street, city, state, zip): Phone 1: Type: Cell Home Work Phone 2: Type: Cell Home Work Phone 3: Type: Cell Home Work Phone number where we can leave you a message: What is your preference for automated appointment reminders? Email Text No reminder Email: Employer: Work Address (street, city, state, zip): Weight: Height: Name you go by: Marital Status: Single Married Partnered Divorced Widowed Child Other Emergency Contact: Relationship: Emergency Contact Phone: Who referred you / how did you hear about MA&W? INSURANCE INFORMATION The insurance/billing information questions are necessary. Please provide your insurance ID card for photocopying. Insurance Company: Phone: Insured's ID #: Group #: Birth Date: As a service to our patients, Meridian Acupuncture & Wellness will submit the charges for medical treatment to the patient's insurance company. However, the patient is primarily responsible for paying any and all medical expenses incurred at this office. We may attempt to verify, in advance, that the patient's insurance company will pay for specific medical procedures. Occasionally, even though coverage was verified before the medical services were provided, the insurance company denies the claim. If the insurance company denies payment or will not pay a portion of the medical bill, the patient is responsible for payment of account balance. Likewise, if the patient has not met his/her deductible under a given insurance plan, the patient will be responsible for the amount of the deductible, in addition to whatever the insurance does not pay. For your convenience copays, coinsurance and deductibles are collected at the time of service. Although we will verify insurance coverage for our records, we strongly encourage our patients to call their insurance company to verify their coverage prior to their first appointment. The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Meridian Acupuncture & Wellness. I also authorize my insurance company to release any information required to process claims. I agree to be responsible for payment of service in the event my insurance company does not agree to pay for these services. (Not signing this document does not release you from responsibility of payment.) Patient’s or Authorized Person’s Signature: Date: From whom are you currently receiving health care? What, if any, contagious disease do you have at this time? What childhood illnesses have you had? What allergies to drugs or food do you have? What current medications do you take and for what? List vitamins/supplements you are currently taking. YOUR MEDICAL HISTORY: Chronic or continuing illnesses: Surgeries, major illnesses, hospitalizations, and major accidents (include year): History of Childhood Trauma? Yes No Are you a former smoker? Yes No How many packs per day? Are you a current smoker? Yes No How many packs per day? What was your last blood pressure reading? What is your normal body temperature reading? FAMILY HISTORY: Age (if living) Father: Mother: Brother(s): Sister(s): Child(ren): Health (G=good P=poor) Father: Mother: Brother(s): Sister(s): Child(ren): WHAT BRINGS YOU HERE TODAY? What is the reason for your visit today? How, when, and where did this condition begin? What types of treatments have you tried, if any? How does this condition impair your daily activities? SYSTEMS REVIEW (Please select all that apply) Fill in every circle: 0=never 1=rarely 2=occasionally 3=frequently 4=always GROUP 1 Sympathetic Dominance 0 1 2 3 4 1 Acid foods upset 0 1 2 3 4 2 Get chilled often 0 1 2 3 4 3 "Lump" in throat 0 1 2 3 4 4 Dry mouth-eyes-nose 0 1 2 3 4 5 Pulse speeds after meal 0 1 2 3 4 6 Keyed up - fail to calm 0 1 2 3 4 7 Cut heals slowly 0 1 2 3 4 8 Gag easily 0 1 2 3 4 9 Unable to relax; startles easily 0 1 2 3 4 10 Extremities cold, clammy 0 1 2 3 4 11 Strong light irritates 0 1 2 3 4 12 Urine amount reduced 0 1 2 3 4 13 Heart pounds after retiring 0 1 2 3 4 14 "Nervous" stomach 0 1 2 3 4 15 Appetite reduced 0 1 2 3 4 16 Cold sweats often 0 1 2 3 4 17 Fever easily raised 0 1 2 3 4 18 Neuralgia-like pains 0 1 2 3 4 19 Staring, blinks little 0 1 2 3 4 20 Sour stomach often GROUP 2 Parasympathetic Dominance 0 1 2 3 4 21 Joint stiffness on arising 0 1 2 3 4 22 Muscle-leg-toe cramps at night 0 1 2 3 4 23 "Butterfly" stomach, cramps 0 1 2 3 4 24 Eyes or nose watery 0 1 2 3 4 25 Eyes blink often 0 1 2 3 4 26 Eyelids swollen, puffy 0 1 2 3 4 27 Indigestion soon after meals 0 1 2 3 4 28 Always seems hungry 0 1 2 3 4 29 Digestion rapid 0 1 2 3 4 30 Vomiting frequent 0 1 2 3 4 31 Hoarseness frequent 0 1 2 3 4 32 Breathing irregular 0 1 2 3 4 33 Pulse slow; feels "irregular" 0 1 2 3 4 34 Gagging reflex slow 0 1 2 3 4 35 Difficulty swallowing 0 1 2 3 4 36 Constipation, diarrhea alternating 0 1 2 3 4 37 "Slow starter" 0 1 2 3 4 38 Get "chilled" infrequently 0 1 2 3 4 39 Perspire easily 0 1 2 3 4 40 Circulation poor, sensitive to cold 0 1 2 3 4 41 Subject to colds, asthma, bronchitis GROUP 3 Sugar Handling 0 1 2 3 4 42 Eat when nervous 0 1 2 3 4 43 Excessive appetite 0 1 2 3 4 44 Hungry between meals 0 1 2 3 4 45 Irritable before meals 0 1 2 3 4 46 Get "shaky" if hungry 0 1 2 3 4 47 Fatigue, eating relieves 0 1 2 3 4 48 "Lightheaded" if meals delayed 0 1 2 3 4 49 Heart palpitates if meals missed or delayed 0 1 2 3 4 50 Afternoon headaches 0 1 2 3 4 51 Overeating sweets upsets 0 1 2 3 4 52 Awaken after few hours sleep - hard to get back to sleep 0 1 2 3 4 53 Crave candy or coffee in afternoons 0 1 2 3 4 54 Moods of depression - "blues" or melancholy 0 1 2 3 4 55 Abnormal craving for sweets or snacks GROUP 4 Cardiovascular 0 1 2 3 4 56 Hands and feet go to sleep easily, numbness 0 1 2 3 4 57 Sigh frequently, "air hunger" 0 1 2 3 4 58 Aware of "breathing heavily" 0 1 2 3 4 59 High altitude discomfort 0 1 2 3 4 60 Opens windows in closed rooms 0 1 2 3 4 61 Susceptible to colds and fevers 0 1 2 3 4 62 Afternoon "yawner" 0 1 2 3 4 63 Get "drowsy" often 0 1 2 3 4 64 Swollen ankles, worse at night 0 1 2 3 4 65 Muscle cramps, worse during exercise; get "charley horses" 0 1 2 3 4 66 Shortness of breath on exertion 0 1 2 3 4 67 Dull pain in chest or radiating into left arm, worse on exertion 0 1 2 3 4 68 Bruise easily, "black and blue" spots 0 1 2 3 4 69 Tendency to anemia 0 1 2 3 4 70 "Nose bleeds" frequent 0 1 2 3 4 71 Noises in head, or "ringing in ears" 0 1 2 3 4 72 Tension under the breastbone, or feeling of "tightness", worse on exertion GROUP 5 Billiary and Liver 0 1 2 3 4 73 Dizziness 0 1 2 3 4 74 Dry skin 0 1 2 3 4 75 Burning feet 0 1 2 3 4 76 Blurred vision 0 1 2 3 4 77 Itching skin and feet 0 1 2 3 4 78 Excessive falling hair 0 1 2 3 4 79 Frequent skin rashes 0 1 2 3 4 80 Bitter, metallic taste in mouth in mornings 0 1 2 3 4 81 Bowel movements painful or difficult 0 1 2 3 4 82 Worrier, feels insecure 0 1 2 3 4 83 Feeling queasy; headache over eyes 0 1 2 3 4 84 Greasy foods upset 0 1 2 3 4 85 Stools light colored 0 1 2 3 4 86 Skin peels on foot soles 0 1 2 3 4 87 Pain between shoulder blades 0 1 2 3 4 88 Use laxatives 0 1 2 3 4 89 Stools alternate from soft to watery 0 1 2 3 4 90 History of gallbladder attacks or gallstones 0 1 2 3 4 91 Sneezing attacks 0 1 2 3 4 92 Dreaming, nightmare type bad dreams 0 1 2 3 4 93 Bad breath (halitosis) 0 1 2 3 4 94 Milk products cause distress 0 1 2 3 4 95 Sensitive to hot weather 0 1 2 3 4 96 Burning or itching anus 0 1 2 3 4 97 Crave sweets GROUP 6 Digestive 0 1 2 3 4 98 Loss of taste for meat 0 1 2 3 4 99 Lower bowel gas several hours after eating 0 1 2 3 4 100 Burning stomach sensations, eating relieves 0 1 2 3 4 101 Coated tongue 0 1 2 3 4 102 Pass large amounts of foul-smelling gas 0 1 2 3 4 103 Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs . 0 1 2 3 4 104 Mucous colitis or "irritable bowel" 0 1 2 3 4 105 Gas shortly after eating 0 1 2 3 4 106 Stomach "bloating" after eating GROUP 7A Hyperthyroid 0 1 2 3 4 107 Insomnia 0 1 2 3 4 108 Nervousness 0 1 2 3 4 109 Can't gain weight 0 1 2 3 4 110 Intolerance to heat 0 1 2 3 4 111 Highly emotional 0 1 2 3 4 112 Flush easily 0 1 2 3 4 113 Night sweats 0 1 2 3 4 114 Thin, moist skin 0 1 2 3 4 115 Inward trembling 0 1 2 3 4 116 Heart palpitates 0 1 2 3 4 117 Increased appetite without weight gain 0 1 2 3 4 118 Pulse fast at rest 0 1 2 3 4 119 Eyelids and face twitch 0 1 2 3 4 120 Irritable and restless 0 1 2 3 4 121 Can't work under pressure GROUP 7B Hypothyroid 0 1 2 3 4 122 Increase in weight 0 1 2 3 4 123 Decrease in appetite 0 1 2 3 4 124 Fatigue easily 0 1 2 3 4 125 Ringing in ears 0 1 2 3 4 126 Sleepy during day 0 1 2 3 4 127 Sensitive to cold 0 1 2 3 4 128 Dry or scaly skin 0 1 2 3 4 129 Constipation 0 1 2 3 4 130 Mental sluggishness 0 1 2 3 4 131 Hair coarse, falls out 0 1 2 3 4 132 Headaches upon arising, wear off during day 0 1 2 3 4 133 Slow pulse, below 65 0 1 2 3 4 134 Frequency of urination 0 1 2 3 4 135 Impaired hearing 0 1 2 3 4 136 Reduced initiative GROUP7C Hyperpituitary 0 1 2 3 4 137 Failing memory 0 1 2 3 4 138 Low blood pressure 0 1 2 3 4 139 Increased sex drive 0 1 2 3 4 140 Headaches, "splitting or rending" type 0 1 2 3 4 141 Decreased sugar tolerance GROUP7D Hypopituitary 0 1 2 3 4 142 Abnormal thirst 0 1 2 3 4 143 Bloating of abdomen 0 1 2 3 4 144 Weight gain around hips or waist 0 1 2 3 4 145 Sex drive reduced or lacking 0 1 2 3 4 146 Tendency to ulcers, colitis 0 1 2 3 4 147 Increased sugar tolerance 0 1 2 3 4 148 Women: menstrual disorders 0 1 2 3 4 149 Young girls: lack of menstrual function GROUP 7E Hyperadrenal 0 1 2 3 4 150 Dizziness 0 1 2 3 4 151 Headaches 0 1 2 3 4 152 Hot flashes 0 1 2 3 4 153 Increased blood pressure 0 1 2 3 4 154 Hair growth on face or body (female) 0 1 2 3 4 155 Sugar in urine (not diabetes) 0 1 2 3 4 156 Masculine tendencies (female) GROUP 7F Hypoadrenal 0 1 2 3 4 157 Weakness, dizziness 0 1 2 3 4 158 Chronic fatigue 0 1 2 3 4 159 Low blood pressure 0 1 2 3 4 160 Nails weak, ridged 0 1 2 3 4 161 Tendency to hives 0 1 2 3 4 162 Arthritic tendencies 0 1 2 3 4 163 Perspiration increase 0 1 2 3 4 164 Bowel disorders 0 1 2 3 4 165 Poor circulation 0 1 2 3 4 166 Swollen ankles 0 1 2 3 4 167 Crave salt 0 1 2 3 4 168 Brown spots or bronzing of skin 0 1 2 3 4 169 Allergies - tendency to asthma 0 1 2 3 4 170 Weakness after colds, influenza 0 1 2 3 4 171 Exhaustion - muscular and nervous 0 1 2 3 4 172 Respiratory disorders GROUP 8 Complex Deficiencies 0 1 2 3 4 173 Muscle weakness 0 1 2 3 4 174 Lack of Stamina 0 1 2 3 4 175 Drowsiness after eating 0 1 2 3 4 176 Muscular soreness 0 1 2 3 4 177 Rapid heart beat 0 1 2 3 4 178 Hyper-irritable 0 1 2 3 4 179 Feeling of a band around your head 0 1 2 3 4 180 Melancholia (feeling of sadness) 0 1 2 3 4 181 Swelling of ankles 0 1 2 3 4 182 Diminished urination 0 1 2 3 4 183 Tendency to consume sweets or carbohydrates 0 1 2 3 4 184 Muscle spasms 0 1 2 3 4 185 Blurred vision 0 1 2 3 4 186 Loss of muscular control 0 1 2 3 4 187 Numbness 0 1 2 3 4 188 Night sweats 0 1 2 3 4 189 Rapid digestion 0 1 2 3 4 190 Sensitivity to noise 0 1 2 3 4 191 Redness of palms of hands and bottom of feet 0 1 2 3 4 192 Visible veins on chest and abdomen 0 1 2 3 4 193 Hemorrhoids 0 1 2 3 4 194 Apprehension (feeling that something bad will happen) 0 1 2 3 4 195 Nervousness causing loss of appetite 0 1 2 3 4 196 Nervousness with indigestion 0 1 2 3 4 197 Gastritis 0 1 2 3 4 198 Forgetfulness 0 1 2 3 4 199 Thinning hair FEMALE ONLY 0=Never 1=rarely 2=occasionally 3=frequently 4=always 0 1 2 3 4 200 Very easily fatigued 0 1 2 3 4 201 Premenstrual tension 0 1 2 3 4 202 Painful menses 0 1 2 3 4 203 Depressed feelings before menstruation 0 1 2 3 4 204 Menstruation excessive and prolonged 0 1 2 3 4 205 Painful breasts 0 1 2 3 4 206 Menstruate too frequently 0 1 2 3 4 207 Vaginal discharge 0 1 2 3 4 208 Hysterectomy / ovaries removed 0 1 2 3 4 209 Menopause hot flashes 0 1 2 3 4 210 Menses scanty or missed 0 1 2 3 4 211 Acne, worse at menses 0 1 2 3 4 212 Depression of long standing At what age did you get your first period: Date of last menstrual cycle: Are you currently on birth control? Yes No If yes, what kind? Are you pregnant now? Yes No Number of days from the start of one period to the start of the next: Average number of days of flow: Are your menstrual cycles spaced regularly? Yes No Flow is: Light Normal Heavy Color is: Light Red Red Dark Red Purple Brown Do you have blood clots? Yes No Does you period cause you pain or cramping? Yes No If yes, when? Before During After period Fibrocystic breasts? Yes No Do you experience any of the following before your period each month? Water retention Breast tenderness or swelling Mental depression Irritability Food cravings Migraines Other Number of pregnancies: Number of abortions: Number of live births: Number of miscarriages: Are you in menopause? Yes No When? MALE ONLY 0=Never 1=rarely 2=occasionally 3=frequently 4=always 0 1 2 3 4 213 Prostate trouble 0 1 2 3 4 214 Urination difficult or dribbling 0 1 2 3 4 215 Night urination frequent 0 1 2 3 4 216 Depression 0 1 2 3 4 217 Pain on inside of legs or heels 0 1 2 3 4 218 Feeling of incomplete bowel evacuation 0 1 2 3 4 219 Lack of energy 0 1 2 3 4 220 Migrating aches and pains 0 1 2 3 4 221 Tire too easily 0 1 2 3 4 222 Avoids activity 0 1 2 3 4 223 Leg nervousness at night 0 1 2 3 4 224 Diminished sex drive Have you been diagnosed with prostate problems? Yes No Have you been diagnosed with infertility? Yes No Thank you for taking the time to fill out this form as completely as possible. Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient’s physical, mental and emotional state. Patient's Name: Date: