Step 1 of 4 - Medical History25%Today's Date* Date Format: MM slash DD slash YYYY Legal Name* First Last Preferred Name First Last PronounDate of Birth* Date Format: MM slash DD slash YYYY Sex*MaleFemaleRelationship StatusAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code HomeCell Phone*Work PhoneOk to leave a voicemail?*YesNoIndicate which phone number*HomeCellWorkEmail Preferred Means of Contact*please indicate oneText messageEmailOccupationEmployed byPrimary Care DoctorInsurance Information**If you would like our office to verify if you have acupuncture benefits, please submit your request at least 48 hours in advance of your appointment by clicking here (https://hhamd.com/insurance-check/)Subscriber Name First Last Date of Birth Date Format: MM slash DD slash YYYY Do you have Medicare?YesNoPrimary Insurance Company (or secondary if you have Medicare)AetnaCareFirst BlueCross BlueShieldGEHAUMRUnited HealthcareInsurance Phone Number (on card)Member ID #:Group ID #:**Please provide us with a copy of your insurance card(s) for claims filing.** My signature below authorizes:-Provider to render treatment and apply for benefits paid directly to the provider - The release of any medical or other information necessary to process this claim -MEDICAL INSURANCE: We have contracts with BC/BS, Carefirst, Aetna and United Healthcare companies, and we will bill them as a service to you. As the responsible party, you are responsible if your insurance company declines to pay for any reason.SignatureDate Date Format: MM slash DD slash YYYY Printed Name First Last Relationship to PatientExperienced Acupuncture/Herbs in the past?*YesNoHeight*WeightAverage Blood Pressure ReadingHow did you hear about us?*Google SearchHealth FairYelpSignFrederick Lifestyle MagazineOther PublicationInternet SearchReferral - Who?Chief ComplaintMain problems you want help with*When did your issue begin?*Did anything initiate the symptoms?*Does anything make it better?*HeatColdMassageRestFatigueOtherDoes anything make it worse?*Have you been given a diagnosis? If so, what?*Past Medical/Family HistoryPlease check all that applySelfFamilyDiabetesChest Pain/AnginaHigh Blood PressureHeart DiseaseHigh CholesterolPacemakerHeadachesKidney StonesCancerOsteoperosisAsthmaStrokeSeizureHIV/AIDSHepatitisStomach UlcerLiver DiseaseHeart PalpitationsArthritisHeart SurgeryBlood ClotsPeripheral Vascular DiseaseTuberculosisDepressionCongestive Heart FailureThyroid DiseaseOther (please list below)Systems Review - Check All That Apply(currently experiencing)Constitutional/General Weight Loss Weight Gain Heat Intolerance Cold Intolerance Poor Appetite Fatigue Easy Bruising Night Sweats Sweat Easily Poor Sleeping Cravings Tastes or smells ChillsEyes Blurry Vision Eye Pain Eye Discharge Eye Redness Glasses Dry Eyes Decrease in Vision FloatersENMT Nose Bleeds Sinus Problems Swollen Lymph Nodes Sore Throat Facial Pain Grinding Teeth Phlegm Lip or Tongue Sores Hearing Loss Ringing in Ears Earaches HeadachesCardiovascular 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 FaintingRespiratory Shortness of Breath Chronic Cough Coughing up Blood History of Tuberculosis Bronchitis Pneumonia AsthmaGastrointestinal Nausea Vomitting Diarrhea Constipation Blood in Stool Bad Breath Abdominal Pain or Cramps Chronic Laxative Use Gas Belching Indigestion HemorrhoidsUro-Genital Frequent UTI's Blood in Urine Painful Urination Incontinence Frequent Urination Decrease in Flow Sores on Genitals Sexual DysfunctionGynecology (Women) Heavy Period Light Period Painful Period Clots with Flow Irregular Periods Vaginal Discharge Breast Lumps PMSNumber of Pregnancies?Number of Births?Age at First Menses?Duration of Menses?Date of Last Menses?Number of Days Between Menses?Skin Rash/Hives Itching Dandruff Ulcerations Eczema Pimples Mole Changes Nail ChangesMusculoskeletal Muscle Aches Joint Swelling Neck Pain Back Pain Shoulder Pain Knee Pain Hip Pain Foot/Ankle Pain Hand/Wrist Pain Frequent Leg Cramps Muscle WeaknessNeuropathy/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 StressEarly Development: Were there any in-utero complications before you were born? Please describe any labor and delivery, natural or C-Section, and how long breast fed:Significant traumas (auto accident, falls, etc):Allergies:Prescription Medications:Medicines, Vitamins, Herbs:Describe any exercise you are currently doing:Describe your daily diet (breakfast, lunch, dinner):Tobacco use? If yes, how often?How much coffee, tea or caffeine per week?How much alcohol do you drink per week?PhoneThis field is for validation purposes and should be left unchanged.
