CSCM - Patient ID Form

Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Preferred Name
Gender

MFMTFFTMNon-Binary
Preferred Pronoun

they/themhe/himshe/her
Preferred Language
English, Spanish, et al.
Place of Birth
Marital Status
Number of Children
Occupation
Employer
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
I give permission to Chicken Soup Chinese Medicine to contact me individually by e-mail regarding appointments, treatment plans, labs and any medical related issues.

YesNo
I give permission to Chicken Soup Chinese Medicine to add me to their e-mail mailing list so I can receive newsletters, updates and special offers*.

YesNo
*Chicken Soup Chinese Medicine values your privacy. If you choose to subscribe to our newsletter, we will send a confirmation request to the email address you provided. You must respond to that confirmation email to initiate your subscription. IF you choose to opt in to Chicken Soup Chinese Medicine, we will not sell, rent, or share your email address or any other personal information. You may revoke this authorization at any time. Please advise us in writing of your desire to withdraw your authorization. Please allow a reasonable processing time for the change in our system to be completed.
Phone Number - Home

Area CodePhone Number
Phone Number - Work

Area CodePhone Number
Phone Number - Cell

Area CodePhone Number
May we use your cell phone number for text communications?

YesNo
If you prefer that we NOT call or leave voicemails at any of the above listed phone numbers, please list which numbers we may NOT call and/or leave voicemails.
Emergency Contact

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Emergency Contact - Relationship to Patient
How did you hear about our clinic?
May we send you a thank-you card?

YesNo
Insurance Information
As a courtesy, Chicken Soup Chinese Medicine will check with your insurance company regarding procedures, treatments or services offered by our clinic. Would you like to include your insurance information?*

YesNo
* If you have Kaiser, any HMO plans, or Anthem/Blue Cross or Blue Shield that are run by American Specialty Health (ASH), these plans do not cover services provided by CSCM. If your insurance is through any of these companies, please click “No”.
We accept in-network insurance including Cigna PPO, United Health Care PPO, Blue Shield PPO, and Sutter Health PPO. We can bill out-of-network insurances once we verify insurance eligibility.
Is your insurance an employee insurance policy?

YesNo
Is the insurance an HMO?

YesNo
Insurance Company
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Number
Member Number
Group Number
Please upload a picture of the FRONT and BACK of your insurance card.

Browse Files

Cancelof
Do you have other health coverage?

YesNo
If yes, what is it?
Does your policy cover acupuncture?

YesNo
Does your policy cover massage?

YesNo
Name of Policy Holder (if other than patient)

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Relationship to Patient
Their policy number
Their group number
Is your problem related to a work injury or accident?

YesNo
If yes, please describe briefly:
Signature
Today's Date

MonthDayYear
Date
Health Information

To best serve your healthcare needs, please include all applicable health information.
Primary Treating Physician
Phone Number

Area CodePhone Number
Oncologist
Phone Number

Area CodePhone Number
Reproductive Endocrinologist
Phone Number

Area CodePhone Number
Hepatologist
Phone Number

Area CodePhone Number
HIV Specialist
Phone Number

Area CodePhone Number
Other Specialist
Phone Number

Area CodePhone Number
Other Specialist
Phone Number

Area CodePhone Number
Other Specialist
Phone Number

Area CodePhone Number
Have you ever been treated with acupuncture?

YesNo
Have you ever had Chinese herbal treatment?

YesNo
If yes, please list conditions treated:
Please state your present complaint, injury, or illness and give a brief history of its development (include dates if possible).
Describe the history of any previous illnesses, accidents, or trauma, etc, including any treatment received and the results:
Please check any current or past conditions:

HIVAIDSHPVCancerDiabetes - Type I, II, IIIAsthmaAllergiesCOPD/emphysemaTuberculosisPneumoniaBronchitis (acute)Bronchitis (chronic)Arthritis (osteo)Arthritis (rheumatoid)High Blood PressureHeart DiseaseStrokeAneurysmAcute Hepatitis (HAV)Acute Hepatitis (other)Chronic Hepatitis (HCV)Chronic Hepatitis (HBV)Other liver diseaseGall bladder diseaseUlcersIrritable bowel syndromeColitisOther gastro-intestinal diseaseDepressionNervous breakdownAnxiety disorderBipolar disorderOther psychological diagnosisPTSDTraumaMenstrual crampsEndometriosisFibroidsOther gynecological disordersHysterectomy (partial)Hysterectomy (total)Infertility (female)Infertility (male)Prostate problemsKidney diseasePolioMeningitis (viral)Meningitis (bacterial)Rheumatic feverRheumatic heart diseaseHashimoto's ThyroiditisThyroid diseaseSeizuresVertigo/dizzinessEye diseaseChildhood diseaseOpportunistic InfectionsOther
If cancer, what type?
If you have any other conditions not listed here, please list below.
Please list all major hospitalizations, surgeries, illnesses, injuries and/or accidents:
Please list current medications/vitamins/herbs/drugs/etc:
Do you use cigarettes?

YesNo
If yes, please describe usage:
Do you use coffee?

YesNo
If yes, please describe usage:
Do you use tea?

YesNo
If yes, please describe usage:
Do you use cola/soda?

YesNo
If yes, please describe usage:
Do you use marijuana?

YesNo
If yes, please describe usage:
Do you use heroin?

YesNo
If yes, please describe usage:
Do you use methamphetamine?

YesNo
If yes, please describe usage:
Do you use alcohol?

YesNo
If yes, please describe usage:
Do you use any other addictive or habitual substances?

YesNo
If yes, please list substance(s) and describe usage:
FAMILY HISTORY - Has anyone in your immediate family ever had any of the following?

CancerHigh blood pressureAllergiesKidney diseaseArthritisGlaucomaTuberculosisAsthmaHeart DiseaseStrokeDiabetes - type 1Diabetes - type 2Diabetes - type 3ObesityPsychological disordersOther
If anyone in your immediate family has had any other conditions not listed here, please list below.
Nutrition, Diet and Eating Habits
What are your food sources?

Omnivore (animal & vegetable source)VegetarianVeganProcessed foodsWhole foods
Do you have any specific food restrictions?

DairyWheatEggsSoyAll glutenOther
What are your current or normal eating habits?

Skip breakfastEat three meals/dayEat two meals/dayEat one meal/dayGraze (small, frequent meals)Eat constantly, hungry or notGenerally eat on the runEat during the night
How many meals do you eat out per week?
Food frequency - please indicate numbers of servings per day for each type of food listed:
Fruits:Type a label
Dairy: Type a label
Vegetables: Type a label
Eggs:   Type a label
Grains:   Type a label
Legumes:   Type a label
Nuts and Seeds:   Type a label
Fish, Meat, Poultry:   Type a label
Patient Signature*

Please use your finger or mouse to create your e-signature.
Today's Date

MonthDayYear
Date
Should be Empty:

Patient Information

Insurance Information

Health Information

Nutrition, Diet and Eating Habits