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Client Info
Client Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Age
*
Date of Birth
*
MM slash DD slash YYYY
Occupation
Email
*
Referred By
Physical Physician
Emergency Contact
*
First
Last
Contact Phone
*
History
Background Information on Primary Complaint
Please list your primary complaint (describe in detail)
*
How long have you had this problem?
Less than one week
Between 1-4 weeks
Between 1-3 months
Between 3-6 months
Between 6 months - 1year
Between 1-3 years
Between 3-5 years
Between 5-10 years
Most of my life
Past Medical and/or Surgical History:
*
Family Medical History (siblings, parents, grandparents)
To better understand the role of acupuncture and Oriental medicine in the care of your primary complaint, I am interested to know what other types of health care professionals you have consulted in the past AND are consulting currently regarding your primary complaint. Please check ALL that apply.
Western Medical Doctor
*
Never
Past Care
Current Care
Naturopathic Doctor
*
Never
Past Care
Current Care
Chiropractor-
*
Never
Past Care
Current Care
Physical Therapist
*
Never
Past Care
Current Care
Massage Therapist
*
Never
Past Care
Current Care
Dietitian/ Nutritionist
*
Never
Past Care
Current Care
Other (please list):
What other forms of treatment are you CURRENTLY using specifically for your primary complaint?
Medication
Nutritional supplements
Homeopathic remedies
Other care, including self-care (please list):
Specific Information on Primary Complaint
In general, how much BODILY discomfort, pain and/ or dysfunction does your problem cause?
*
None
Very Mild
Mild
Moderate
Severe
Very Severe
In general, how much EMOTIONAL (mental) discomfort, pain and/ or dysfunction does your problem cause?
*
None
Very Mild
Mild
Moderate
Severe
Very Severe
IMPACT ON WORK ACTIVITIES
In general, how much does your primary complaint interfere with your work, both inside and outside of the home?
*
N/A
Not at all
A little bit
Moderately
Quite a bit
Extremely
Are you experiencing any of the following issues with your work (inside and outside of the home) by your primary complaint?
Cut down on the amount of time you would like to spend at work.
*
N/A
Not at all
A little bit
Moderately
Quite a bit
Extremely
Accomplished less than you would like.
*
N/A
Not at all
A little bit
Moderately
Quite a bit
Extremely
Do not work as carefully as usual.
*
N/A
Not at all
A little bit
Moderately
Quite a bit
Extremely
IMPACT ON SOCIAL ACTIVITIES
In general, how much does your primary complaint interfere with your usual social activities?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Limited in the amount of time you are able to spend on your usual social activities.
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Less interested in participating in your usual social activities.
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
IMPACT ON EXERCISE ACTIVITIES
In general, how much does your primary complaint interfere with your usual exercise activities?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Are you experiencing any of the following issues with your usual exercise regimen by your primary complaint?
Limited in your ability to do your usual exercise activities.
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Cut down on the amount of time you spent on your usual exercise activities.
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
Less interested in participating in your usual exercise activities.
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
General Health & Well Being Questions:
Please use the following letters to indicate if you have any of the following symptoms:
Sleep:
Trouble falling asleep
*
Never
In the past
Currently experiencing
Wake in middle of the night
*
Never
In the past
Currently experiencing
Insomnia
*
Never
In the past
Currently experiencing
Dream disturbed sleep
*
Never
In the past
Currently experiencing
Restless sleep
*
Never
In the past
Currently experiencing
Wake up tired
*
Never
In the past
Currently experiencing
Digestion
Poor appetite
*
Never
In the past
Currently experiencing
Excessive appetite
*
Never
In the past
Currently experiencing
Gas, bloating
*
Never
In the past
Currently experiencing
Heartburn
*
Never
In the past
Currently experiencing
Indigestion
*
Never
In the past
Currently experiencing
Nausea, vomit
*
Never
In the past
Currently experiencing
Food allergies or sensitivities
*
Never
In the past
Currently experiencing
Cravings?
General
Catch a cold easily
*
Never
In the past
Currently experiencing
Loss of weight
*
Never
In the past
Currently experiencing
Weight gain
*
Never
In the past
Currently experiencing
High blood pressure
*
Never
In the past
Currently experiencing
High cholesterol
*
Never
In the past
Currently experiencing
Numbness or tingling
*
Never
In the past
Currently experiencing
Energy
Level
Poor
Fair
Good
Very Good
Excellent
Bowel Elimination
Diarrhea
*
Never
In the past
Currently experiencing
Loose Stools
*
Never
In the past
Currently experiencing
Constipation
*
Never
In the past
Currently experiencing
Hemorrhoids
*
Never
In the past
Currently experiencing
Painful movements
*
Never
In the past
Currently experiencing
Emotional State
Generally happy
*
Never
In the past
Currently experiencing
Tend to be sad
*
Never
In the past
Currently experiencing
Depressed
*
Never
In the past
Currently experiencing
Anxious
*
Never
In the past
Currently experiencing
Easily stressed
*
Never
In the past
Currently experiencing
Easily angered
*
Never
In the past
Currently experiencing
Fearful
*
Never
In the past
Currently experiencing
Respiratory
Asthma
*
Never
In the past
Currently experiencing
Shortness of breathe
*
Never
In the past
Currently experiencing
Excess phlegm production
*
Never
In the past
Currently experiencing
Wheeze
*
Never
In the past
Currently experiencing
Tight chest or chest pain
*
Never
In the past
Currently experiencing
Cough
*
Never
In the past
Currently experiencing
Sigh a lot
*
Never
In the past
Currently experiencing
Urination
Painful
*
Never
In the past
Currently experiencing
Urgency
*
Never
In the past
Currently experiencing
Wake to urinate
*
Never
In the past
Currently experiencing
Blood in urine
*
Never
In the past
Currently experiencing
Cloudy
*
Never
In the past
Currently experiencing
Strong odor
*
Never
In the past
Currently experiencing
Respiratory
Level
Poor
Fair
Good
Very Good
Excellent
Eyes
Dry eyes
*
Never
In the past
Currently experiencing
Itchy eyes
*
Never
In the past
Currently experiencing
Red eyes
*
Never
In the past
Currently experiencing
Blurred vision
*
Never
In the past
Currently experiencing
Floaters/Spots in eyes
*
Never
In the past
Currently experiencing
Mouth
Grind teeth
*
Never
In the past
Currently experiencing
T.M.J
*
Never
In the past
Currently experiencing
Mouth sores
*
Never
In the past
Currently experiencing
Weird taste in mouth
*
Never
In the past
Currently experiencing
Dry mouth
*
Never
In the past
Currently experiencing
Nose
Runny nose
*
Never
In the past
Currently experiencing
Nosebleeds
*
Never
In the past
Currently experiencing
Sinusitis
*
Never
In the past
Currently experiencing
Allergies
*
Never
In the past
Currently experiencing
Ears
Ringing in ears
*
Never
In the past
Currently experiencing
Loss of hearing
*
Never
In the past
Currently experiencing
Earaches
*
Never
In the past
Currently experiencing
Do you experience any pain in your body? Please circle one or more.
*
Neck/Shoulder
Upper Back
Low Back
Sciatica
Joint Pain
Arthritis
Headaches
Migraines
Other
Explain Other
*
Rating
*
1
2
3
4
5
6
7
8
9
10
Quality of Pain
*
Dull
Sharp
Achy
Throbbing
Burning
Intermittent
Wandering
Other
Explain Other
*
Consent to Treatment of Minor
Because the selected age was below 18, a parent or guardian signature is required. br />
By my signature below, I hereby authorize beyond massage Aspen Staff to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.
Parent/Guardian Name
First
Last
Parent/Guardian Signature
*
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