Patient Information Form

The Patient Information Form can be completed online or printed. To submit online, please fill out the form below, then click the 'submit' button at the very end. Otherwise, to print the form, please click here.

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PATIENT INFORMATION
First Name:
Middle Inital:
Last Name:
Age:
Gender:
Date of Birth:
Home Address (street, city, state, zip):
Phone 1:
Type:
Phone 2:
Type:
Phone 3:
Type:
Phone number where we can leave you a message:
What is your preference for automated appointment reminders?
Email:
Employer:
Work Address (street, city, state, zip):
Weight:
Height:
Name you go by:
Marital Status:
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?
Are you a former smoker?
How many packs per day?
Are you a current smoker?
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
1 Acid foods upset
2 Get chilled often
3 "Lump" in throat
4 Dry mouth-eyes-nose
5 Pulse speeds after meal
6 Keyed up - fail to calm
7 Cut heals slowly
8 Gag easily
9 Unable to relax; startles easily
10 Extremities cold, clammy
11 Strong light irritates
12 Urine amount reduced
13 Heart pounds after retiring
14 "Nervous" stomach
15 Appetite reduced
16 Cold sweats often
17 Fever easily raised
18 Neuralgia-like pains
19 Staring, blinks little
20 Sour stomach often
GROUP 2 Parasympathetic Dominance
21 Joint stiffness on arising
22 Muscle-leg-toe cramps at night
23 "Butterfly" stomach, cramps
24 Eyes or nose watery
25 Eyes blink often
26 Eyelids swollen, puffy
27 Indigestion soon after meals
28 Always seems hungry
29 Digestion rapid
30 Vomiting frequent
31 Hoarseness frequent
32 Breathing irregular
33 Pulse slow; feels "irregular"
34 Gagging reflex slow
35 Difficulty swallowing
36 Constipation, diarrhea alternating
37 "Slow starter"
38 Get "chilled" infrequently
39 Perspire easily
40 Circulation poor, sensitive to cold
41 Subject to colds, asthma, bronchitis
GROUP 3 Sugar Handling
42 Eat when nervous
43 Excessive appetite
44 Hungry between meals
45 Irritable before meals
46 Get "shaky" if hungry
47 Fatigue, eating relieves
48 "Lightheaded" if meals delayed
49 Heart palpitates if meals missed or delayed
50 Afternoon headaches
51 Overeating sweets upsets
52 Awaken after few hours sleep - hard to get back to sleep
53 Crave candy or coffee in afternoons
54 Moods of depression - "blues" or melancholy
55 Abnormal craving for sweets or snacks
GROUP 4 Cardiovascular
56 Hands and feet go to sleep easily, numbness
57 Sigh frequently, "air hunger"
58 Aware of "breathing heavily"
59 High altitude discomfort
60 Opens windows in closed rooms
61 Susceptible to colds and fevers
62 Afternoon "yawner"
63 Get "drowsy" often
64 Swollen ankles, worse at night
65 Muscle cramps, worse during exercise; get "charley horses"
66 Shortness of breath on exertion
67 Dull pain in chest or radiating into left arm, worse on exertion
68 Bruise easily, "black and blue" spots
69 Tendency to anemia
70 "Nose bleeds" frequent
71 Noises in head, or "ringing in ears"
72 Tension under the breastbone, or feeling of "tightness", worse on exertion
GROUP 5 Billiary and Liver
73 Dizziness
74 Dry skin
75 Burning feet
76 Blurred vision
77 Itching skin and feet
78 Excessive falling hair
79 Frequent skin rashes
80 Bitter, metallic taste in mouth in mornings
81 Bowel movements painful or difficult
82 Worrier, feels insecure
83 Feeling queasy; headache over eyes
84 Greasy foods upset
85 Stools light colored
86 Skin peels on foot soles
87 Pain between shoulder blades
88 Use laxatives
89 Stools alternate from soft to watery
90 History of gallbladder attacks or gallstones
91 Sneezing attacks
92 Dreaming, nightmare type bad dreams
93 Bad breath (halitosis)
94 Milk products cause distress
95 Sensitive to hot weather
96 Burning or itching anus
97 Crave sweets
GROUP 6 Digestive
98 Loss of taste for meat
99 Lower bowel gas several hours after eating
100 Burning stomach sensations, eating relieves
101 Coated tongue
102 Pass large amounts of foul-smelling gas
103 Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs .
104 Mucous colitis or "irritable bowel"
105 Gas shortly after eating
106 Stomach "bloating" after eating
GROUP 7A Hyperthyroid
107 Insomnia
108 Nervousness
109 Can't gain weight
110 Intolerance to heat
111 Highly emotional
112 Flush easily
113 Night sweats
114 Thin, moist skin
115 Inward trembling
116 Heart palpitates
117 Increased appetite without weight gain
118 Pulse fast at rest
119 Eyelids and face twitch
120 Irritable and restless
121 Can't work under pressure
GROUP 7B Hypothyroid
122 Increase in weight
123 Decrease in appetite
124 Fatigue easily
125 Ringing in ears
126 Sleepy during day
127 Sensitive to cold
128 Dry or scaly skin
129 Constipation
130 Mental sluggishness
131 Hair coarse, falls out
132 Headaches upon arising, wear off during day
133 Slow pulse, below 65
134 Frequency of urination
135 Impaired hearing
136 Reduced initiative
GROUP7C Hyperpituitary
137 Failing memory
138 Low blood pressure
139 Increased sex drive
140 Headaches, "splitting or rending" type
141 Decreased sugar tolerance
GROUP7D Hypopituitary
142 Abnormal thirst
143 Bloating of abdomen
144 Weight gain around hips or waist
145 Sex drive reduced or lacking
146 Tendency to ulcers, colitis
147 Increased sugar tolerance
148 Women: menstrual disorders
149 Young girls: lack of menstrual function
GROUP 7E Hyperadrenal
150 Dizziness
151 Headaches
152 Hot flashes
153 Increased blood pressure
154 Hair growth on face or body (female)
155 Sugar in urine (not diabetes)
156 Masculine tendencies (female)
GROUP 7F Hypoadrenal
157 Weakness, dizziness
158 Chronic fatigue
159 Low blood pressure
160 Nails weak, ridged
161 Tendency to hives
162 Arthritic tendencies
163 Perspiration increase
164 Bowel disorders
165 Poor circulation
166 Swollen ankles
167 Crave salt
168 Brown spots or bronzing of skin
169 Allergies - tendency to asthma
170 Weakness after colds, influenza
171 Exhaustion - muscular and nervous
172 Respiratory disorders
GROUP 8 Complex Deficiencies
173 Muscle weakness
174 Lack of Stamina
175 Drowsiness after eating
176 Muscular soreness
177 Rapid heart beat
178 Hyper-irritable
179 Feeling of a band around your head
180 Melancholia (feeling of sadness)
181 Swelling of ankles
182 Diminished urination
183 Tendency to consume sweets or carbohydrates
184 Muscle spasms
185 Blurred vision
186 Loss of muscular control
187 Numbness
188 Night sweats
189 Rapid digestion
190 Sensitivity to noise
191 Redness of palms of hands and bottom of feet
192 Visible veins on chest and abdomen
193 Hemorrhoids
194 Apprehension (feeling that something bad will happen)
195 Nervousness causing loss of appetite
196 Nervousness with indigestion
197 Gastritis
198 Forgetfulness
199 Thinning hair

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: