TIBOA New Patient Form 2

TIBOA New Patient Form 2
The following questions relate to your current and previous health condition. All of the information is held in the strictest of confidence. No information will be disclosed or shared without your written consent.
Name

First NameLast Name
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number - Daytime
Please enter a valid phone number.
Phone Number - Evening
Please enter a valid phone number.
Email
example@example.com
Height
Weight
Gender
Preferred Pronouns
Emergency Contact Person
Emergency Contact Phone Number
Occupation
How did you hear about us?

GoogleAnother health practitionerFriend / family member referralFacebookHealthprofsInternet searchOther
If you were referred, who can we thank for referring you?
Have you ever had Acupuncture before? If so, was the treatment effective?
What brought you in today?
When did you first notice the problem?
What previous medical test, diagnosis and /or treatments have you had for this problem?
How has the treatment helped?
What other health issues/ symptoms do you wish to address? Please list them in order of importance.
If you are coming in for a body pain issue, where is the pain located?
How would you characterize your pain?

dullachysharpstabbingnumbnesstinglingelectricalburningconcentrated areadispersedOther
Describe the onset of the pain. Please include if it was gradual or acute.
What helps the pain or makes it worse?
Are you using any of the below?

dry heatdamp heaticetopical analgesicsTENS unitCBD topical
Are there any movements that aggravate the pain?
How does exercise affect the pain?
Do any medications help the pain?
At what time of the day is the pain/discomfort at its worst?
What is the frequency of the pain/discomfort?

constanton and offWorse at restWorse with activity
Are you currently under medical care? If yes, please explain.
Who is your primary care physician?
Physician's phone number
Please enter a valid phone number.
Please indicate if you see any of the healthcare practitioners from the list below:

ChiropractorPhysical TherapistMassage TherapistNutritionistOsteopathHerbalistExercise PhysiologistCranial Sacral therapistNaturopathHomeopathKinesiologistSomatic/Movement TherapistStructural Integration Therapist
Are you currently seeing a psychotherapist or attending regular support group meetings? If yes, please elaborate.
Please list your current medications including prescriptions, over the counter and natural remedies and supplements ( including homeopathy, single herbs, herbal formulas, vitamins and nutritional supplements). Please include the doses and how long you have been taking them.
Have you had any accidents/ injuries? If so, what were they? Please include the year and treatment received.
Have you had any surgeries? If so, please include the year.
Have you had any serious illnesses? If yes, please elaborate.
Please list what you do for exercise and/or stress reduction including the frequency.
Please list any allergies or sensitivities that you have including drugs/medications, foods, topicals, latex, airborne inhalants etc...
Do you have any of the below?

PacemakerHearing aidsBreast implantsProsthesisMetal plates or screwsDesensitized area of the body/ nerve damage
How would you rate your level of health from 1 ( poor) to 10 ( excellent)?
How would you rate your current level of energy from 1 ( poor) to 10 ( excellent)?
Do you smoke? If yes, please include the amount per day
Do you drink alcohol? If yes, how much per week?
Do you drink coffee? If yes, how much per week?
Do you drink soda's? if yes, how much per week?
Please mark all that apply whether in past or present history. Use the OTHER category at the end to add any symptoms not listed or to elaborate on ones checked above.
General:

tired/lack of energy/fatigueweakfrequent colds or other illnessesmigrating aches & painsgallstonesexcessive sweatinglack of sweating during activity or heatdizziness/fainting/vertigotendency to be coldtendency to be warm/hothigh cholesterolcracked nailsridges on nailscracked skin on fingers
Musculoskeletal:

swollen jointsstiff jointspainful jointsosteo-arthritisbroken bones/fracturesgoutsprainsstrainslow back painhip painleg painankle/foot painneck painshoulder painarm painwrist/hand painjaw pain/TMJ dysfunction/jaw clicking or poppingspasms/cramps/twitchesloss of grip strengthfrequent dislocationsbursitistendinitis/tendinosiscan't raise arm above shoulder levelpain worse with standingpain worse with activitypain worse with bendingpain worse at night or while lying downpain worse in the morningpain worse with sitting
Gastro:

frequent gasbloatinggas and bloating only after eatingchronic constipationdiarrhea/loose stooldiverticulitis/diverticulosisI.B.S.Chrone'sH. Pylori overgrowthCandidaS.I.B.O.food allergies/sensitivitiesbruise easilyexcessive appetitediminished appetitenauseaG.E.R.D.burpingchronic hiccupscramping/abdominal pain after eatingUlcerative colitissour taste in the mouthbitter taste in the mouthsugar cravingspain under ribcageleft side abdominal painright side abdominal painpain relieved with emptying bowelgingivitisbleeding gumsmouth sores/canker sores
Eyes/Vision:

nearsightednessfarsightednessblurred visiondry eyesitchy eyesredness or burningfrequent eye infectionschalazions/styesBlepharitiseyes watering excessivelysensitivity to lightpuffinessnight blindnessCataractsGlaucomaMacular Degenerationfloatersweepy eyes
Respiratory/Derma:

wheezingChronic coughchronic scratchy and dry throatHayfever/seasonal allergiesPsoriasisExcemaRosaceaAthletes Footrasheshiveschronic congestion/sinusitispost nasal dripasthmainjury to noseblocked feeling in throat/lump in throatthroat irritationshortness of breath
Nephro/Endocrin/Uro:

hypothyroidismhyperthyroidismkidney stoneslow libidochronic fatiguechronic low back painknee weaknessankle weaknessankle swelllinghair losstinnitus/ringing in the earschronic urinary tract infectionsfrequent urinationdifficulty with urinationfrequent urgencyhearing lossOsteoporosis/OsteopeniaInterstitial CystitisDiabeteshistory of kidney infectionhistory of pancreatitisgoiterCushing'sP.C.O.S.ovarian cystsGrave'sAdrenal insufficiency/Addision'sHashimoto's
Circulatory/Cardio:

high blood pressurelow blood pressureblocked arteriesarterial stentsvaricose veinsDVTDiagnosed heart diseasecongestive heart failureknown blood clotshistory of heart attack/myocardial infarction
Shen:

depressionanxietyworryexcessive irritabilityanorexiabulimiamood swingsobsessive thinking
Auto/Neuro:

Rheumatoid ArthritisPsoriatic ArthritisAmyloidosisLupusEpstein-BarrMononucleosisFibromyalgiaEpilepsynumbnessneuropathystrokeaneurismParkinson'sMultiple Sclerosisalopecia
OTHER symptoms /health issues not listed above ( or area to elaborate on symptoms checked from above:
Do you presently or have you had any Cancer or tumors? If so, please elabotrate
Have you had Covid-19? If yes, when?
Have you had a Covid-19 vaccination?

yes, I am fully vaccinatedyes, I am partially vaccinatednoType option 4
Do you have any infectious disease? If yes, please elaborate.
Do you wake up feeling refreshed?
Do you have trouble FALLING asleep?
Do you have trouble STAYING asleep?
Is your sleep disrupted by any of the following?

vivid dreamsnight terrorsfrequent urinationpainnight sweatshot flashesrestless legsrestless armsoverthinking
Would you describe your sleep as restless?
What do you do to facilitate a good nights rest?
Please share an example of your typical meals for the day:
Breakfast:
Lunch:
Dinner:
Snacks:
For diagnostic purposes, if possible, please stick out your tongue and take a photo with your mouth open so that we can see the back of the tongue as well as the front.
I have stated my pertinent medical conditions/history and will update the practitioner of any changes in my health status. I understand that my failure to do so may pose a threat to my health and physical well being and I do not hold The Integrated Body of Atlanta L.L.C. or my practitioner liable for anything that may arise from a failure to disclose information on my part.
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