"*" indicates required fields Step 1 of 2 – Medical History 50% ACUPUNCTUREPatient Intake and Medical HistoryToday's Date* Month Day Year Legal Full Name of Patient* First Last Preferred Name First Last Date of Birth* Month Day Year Gender*Note: For patients using insurance, this field must match what is on file with your insurance companyGender at BirthPronounRelationship StatusAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cell Phone*HomeWork PhoneConsent to leave a voicemail?* Home Cell Work SMS Consent* I consent to receiving SMS text messages from Holistic Health Associates on my cell phone. I do NOT consent to receiving SMS text messages from Holistic Health Associates on my cell phone. By checking this box, I recognize that I will not be receiving any text messages from Holistic Health Associates, including appointment reminders. See SMS Terms & Conditions I can change my decision for consent at any time by providing consent in writing to contactus@hhamd.com.Email OccupationEmployerLanguage* English Spanish Other Race*Emergency Contact Name*Emergency Contact Phone*Have you had Acupuncture before?* Yes No Have you taken Chinese Herbals Medicine?* Yes No Primary Care DoctorHeightWeightAverage Blood Pressure ReadingReferred byWe want to do everything we can to make you comfortable. Do you require additional accomodations?* Yes No If yes, please describeAre you currently pregnant?* Yes No Do you have issues climbing stairs? (we have upper level treatment rooms)* Yes No Why are you seeking treatment?*What is the most important activity that you are currently limited from doing?*Is the reason you are coming related to a Workers Comp, Auto Accident or Personal Injury case?* Yes No Our office does not process to your personal health insurance for Workers Comp, Auto Accident or Personal Injury related cases unless you provide a Letter of Subrogation from your insurance company or a PIP exhaust letter to our office. If you are unable to provide that to our office, you will be required to pay the self-pay rate at each appointment and we will not process your claim to your insurance. We can give you the appropriate supporting documents to seek reimbursement on your own. If you have any questions or would like to speak to someone further, please call our main number at 301-620-1414 and leave a voicemail with our Insurance Team or email insurance@hhamd.com. When did your issue(s) begin?*Did anything initiate symptoms?*Does anything make it better?*HeatColdMassageRestFatigueOtherList any existing diagnoses*Do you have an insurance plan that offers acupuncture coverage?* No Yes, and I have submitted my insurance information to be checked for acupuncture benefits Yes, but I will not be using my insurance to process my visits How did you hear about us?*Google/Internet SearchPatient ReferralSocial MediaPostcard MailingYelpSignAd in Local PublicationHealth FairReferral – Who?Medical/Family HistoryPlease select if you or your immediate family member has history with these conditions.Please check all that apply*SelfFamilySelf & FamilyN/ADiabetesChest Pain/AnginaHigh Blood PressureHeart DiseaseHigh CholesterolPacemakerHeadachesKidney StonesCancerOsteoperosisAsthmaStrokeSeizureHIV/AIDSHepatitisStomach UlcerLiver DiseaseHeart PalpitationsArthritisHeart SurgeryBlood ClotsPeripheral Vascular DiseaseTuberculosisDepressionCongestive Heart FailureThyroid DiseaseHeart AttackAre you currently undergoing cancer treatment?* Yes No Any other significant or family medical history?List any allergies*Were there any in-utero complications before you were born?Any complications during your birth? Natural? C-section?Were you breast fed or bottle fed? How long?Significant traumas (auto accident, falls, etc.)?Prescription Medications (list name, dosage, and frequency)*Routine Over-the-Counter Medicines, Vitamins, Herbs*Do you have a regular Exercise Program?* Yes No DescribeDescribe your average daily diet (Breakfast, Lunch, Dinner)*Do you smoke cigarettes?* Yes No If yes, how many per day?How much coffee, tea or caffeine per week?*How much alcohol per week?*Please describe any use of drugs for non-medical purposes* Current State of Health – Check All That ApplyPlease mark the checkbox if you have experienced any of these conditions in the past 4 weeks.Constitutional/General Weight Loss Weight Gain Heat Intolerance Cold Intolerance Poor Appetite Fatigue Easy Bruising Night Sweats Sweat Easily Poor Sleeping Cravings Strange Tastes or smells Chills Eyes Blurry Vision Eye Pain Eye Discharge Eye Redness Glasses Dry Eyes Decrease in Vision Floaters ENMT Nose Bleeds Sinus Problems Swollen Lymph Nodes Sore Throat Facial Pain Grinding Teeth Phlegm Lip or Tongue Sores Hearing Loss Ringing in Ears Earaches Headaches Cardiovascular Chest Pain Palpitations Rapid Heart Beat Poor Circulation Swelling in Extremities High Blood Pressure Low Blood Pressure Irregular Heart Beats Cold Hands or Feet Blood Clots Fainting Respiratory Shortness of Breath Chronic Cough Coughing up Blood History of Tuberculosis Bronchitis Pneumonia Asthma Gastrointestinal Nausea Vomitting Diarrhea Constipation Blood in Stool Bad Breath Abdominal Pain or Cramps Chronic Laxative Use Gas Belching Indigestion Hemorrhoids Uro-Genital Frequent UTI’s Blood in Urine Painful Urination Incontinence Frequent Urination Decrease in Flow Sores on Genitals Sexual Dysfunction Skin Rash/Hives Itching Dandruff Ulcerations Eczema Pimples Mole Changes Nail Changes Musculoskeletal Muscle Aches Joint Swelling Neck Pain Back Pain Shoulder Pain Knee Pain Hip Pain Foot/Ankle Pain Hand/Wrist Pain Frequent Leg Cramps Muscle Weakness Neuropathy/Psychology Anxiety Depression Suicidal Thoughts Panic Attacks Seizures Concussion Bad Temper Dizziness/Vertigo Poor Memory Loss of Balance Numbness Tremors Alcohol or Drug Dependence Use of Anti-Depressants Easily Susceptible to Stress Migraine Headache Gynecology (Women) Currently pregnant Heavy Period Light Period Painful Period Clots with Flow Irregular Periods Vaginal Discharge Breast Lumps Irregular PMS Age at First Menses?Date of Last Menses?Average Duration of Menses?Average No. of Days Between Menses?Do you use birth control?* Yes No No. of Pregnancies?No. of Premature Births?No. of Previous Live Births?No. of Miscarriages?No. of Abortions?Anything We Missed or You Want to Tell Us?NameThis field is for validation purposes and should be left unchanged.
