Health History Questionnaire, Sage Acupuncture

Intake Form

Personal Information

Full Name *

Pronouns

Date *

Date of Birth *

Address *

City, State, Zip Code *

Email *

Mobile # *

Alt #

Occupation

Have you been treated by acupuncture before?

Emergency Contact

Phone #

Relationship

Referred By

I have been evaluated by a physician for the condition(s) being treated within the past 12 months *

Name of doctors (ex: GP, OB/GYN, Reproductive Endocrinologist)

May we share information with your other healthcare providers? *

Initial

Lifestyle

List any regular exposure to heat (sauna, hot yoga, jacuzzi):

List any regular exposure to chemicals or x-rays:

List any allergies (seasonal, food, chemicals, drugs):

If you smoke cigarettes, list the amount per day/week:

If you drink alcohol, list the amount per day/week:

If you use cannabis with THC, list the amount per day/week:

If you exercise, list the type and frequency per day/week:

If you follow a particular diet plan what is it?

Describe your average daily diet

Morning

Afternoon

Evening

Snacks

Family History

List any significant family history of hereditary, genetic, or reproductive disorders that you are aware of.

In addition to acupuncture I am interested in receiving the following (for 60 minute consultations only)

Nutritional Advice

Supplement recommendations

Herbal recommendations (If Yes, I acknowledge that I am not currently using medication to try to conceive).

Obstetrics and Gynecology History

List any of the following that apply to you:
Endometriosis
Polycystic ovaries
Diminishes ovarian reserve
Fibroids
Polyps
Blocked/damaged fallopian tubes
Sexually Transmitted Disease
Unexplained Infertility
Other

List conditions:

If you are trying to conceive, when did you start actively trying

Are you charting your BBT temperatures?

Yes

List the date and result for any of the following lab tests that you have received:

Hysterosalpingogram (HSG)

Hysteroscopy

Laparoscopy

Day 3 FSH

Day 3 Estradiol

AMH

Progesterone

Prolactin

Antral Follicle Count

Thyroid tests (ex: TSH)

Testosterone

Vitamin D

Immunology Testing

DHEAs

Other

List any assisted reproductive procedures starting with the most recent (ex: Egg Retrieval, FET, medicated IUI, or un-medicated IUI).
If applicable, please include the number of embryos frozen, genetically tested, and transferred under outcomes.

Date, Procedure, Outcome

Menstrual History

Age of first menstrual cycle:

Date of onset of last menstrual cycle:

Are your cycles regular:

Cycle length (number of days from the start of one cycle to the start of the next):

If you have regular cycles what day do you usually ovulate on:

How do you track ovulation (ovulation predictor kit, increased vaginal fluid):

Do you notice stretchy, clear, vaginal discharge before ovulation:

Amount of flow (Spotting, Light, Moderate Heavy) on each cycle day (ex: SLMML)

What color is your menstrual blood (ex: pink, bright red, brown, purple, black):

Do you have clots (tissue in menstrual flow)? If Yes what size (ex: almond, egg yolk)

none

mild (grain of rice size)

moderate (almond size)

severe (egg yolk size)

Symptoms before menses starts: (ex: Breast changes, Irritability, Fatigue, Bowel changes, Low back pain, Cramps).

Symptoms after onset of menses: (ex: Breast changes, Irritability, Fatigue, Bowel changes, Low back pain, Cramps).

If you have used hormonal contraception (ex: birth control, Mirena, NuvaRing, medicated IUD), please list the form and dates taken.

List any pregnancies including the date of conception, how long it took to conceive, and if there were losses or complications.

Date, time to conceive, complications:

Andrology History

Medical History
Please list any conditions that you have or have had below including but not limited to the following: Undescended testicles, Injury to testicles, Hernia Repair, Varicocele, Vasectomy, Bladder or prostate issues, Urinary tract infection, Sexually transmitted disease, Problems achieving erection, Problems with sex drive, Abnormal sexual development, Fever within the last 3 months, Family history of fertility problems, Hormonal problems (ex: diabetes, thyroid), Late puberty, History of mumps, Neurological problems.

List conditions or concerns below:

Numer of pregnancies with current partner:

Number of pregnancies with previous partner(s):

Age(s) of children, if any:

If applicable, how long have you been trying to conceive (months/years)

Semen analysis results

Count

Motility

Morphology

Volume

Comments on any of the above:

Informed Consent

I, *

do hereby request and give permission to receive treatment from Sage Acupuncture LLC, and any affiliated Licensed Acupuncturist. Traditional Chinese Medical treatments include various modalities including but not limited to acupuncture, cupping, gua sha, herbal, and dietary supplements. I understand that I have the right to inquire about and refuse any part of the treatment.

I understand and am informed that, as in allopathic medicine, in the practice of Traditional Chinese Medicine there are some risks of treatment. I understand that although these risks are unlikely to occur, they are possible. These risks include but are not limited to: bleeding, bruising, nerve damage, punctured organs, aggravation of symptoms, the appearance of new symptoms, fainting, and fatigue. I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise such judgment to be in my best interest based on the known facts at the time. Although I am aware that acupuncture and the other procedures used in Traditional Chinese Medicine have helped millions of people, I understand that no guarantee of cure or improvement in my condition is given or implied.

Policies & Procedures

Appointment Reminders and Follow Up Communication

We may use or disclose your health information to provide you with appointment reminders and follow up communication via phone, voicemail, text (including SMS), email, or letter.

Privacy Practices
I have reviewed Sage Acupuncture LLC’s notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.

Payment
Payment is due at the time of service. We accept cash, checks, and most major credit cards.
Your appointment time is reserved specifically for you. In the event of a missed appointment or an appointment canceled for any reason with less than 24 business hours notice you will be charged a fee.
A $30 fee will be charged for returned checks.
We reserve the right to change our fee scale without notice.

Media Release
Any photographs, audio or video recordings of myself or my family that I participate in or submit to Sage Acupuncture LLC, may be used for any purpose without compensation in perpetuity.

I have completed this form to the best of my knowledge. I have read and understood the Informed Consent and Privacies & Procedures information. By signing below I agree to a course of treatment in Traditional Chinese Medicine and intend this consent form to cover the entire course of treatment for my present condition as well as any future condition(s) for which I seek treatment with this practice.

Finish and Submit

I have completed this form to the best of my knowledge. I have read and understand the informed consent, privacy, and procedures information. By entering my initials below I agree to a course of treatment in Oriental Medicine and intend this consent form to cover the entire course of treatment for my present condition as well as any future condition(s) for which I seek treatment with this practice.

Patient’s Name *