New Patient Health History - Qigong Healing and Chinese Medicine

New Patient Health History - Qigong Healing and Chinese Medicine

Standard online intake form using all fields and sections extracted from the attached PDF.
Patient Information
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Name
Legal Name (if different)

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Pronouns
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Email Contact Consent
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Occupation
Employer
How did you hear about our practice?
Emergency Contact
Emergency Contact Name

First NameMiddle NameLast Name
Relationship to Patient
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Concern and Treatment Goals
Top three reasons for seeking treatment
What would you like to achieve through treatment?
Primary concern today
When did it begin?
Onset
Onset - Please explain
Diagnosis, Prior Care, and Pain
Have you received a medical diagnosis?
Diagnosis
Treatments already tried

Other
Treatments tried - Other
Did these treatments help?
Impact on Work/Sleep/Exercise/Mood/Overall Quality of Life

0

1

2

3

4

5

6

7

8

9

10

0 is No impact, 10 is Severe impact
Current Pain Level

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst pain
Worst Pain (Past Week)

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst pain
Painful areas
Pain - Additional comments
Medical History and Family History
Medical History - Conditions

Other
Medical History - Other Condition
Surgeries
Major Injuries, Falls, or Auto Accidents
Significant Dental Work
Allergies
Family Health History

Other
Family History - Other Condition
Medications, Stress, Exercise, Sleep, Diet, and Habits
Current Medications & Supplements
Stress Level

0

1

2

3

4

5

6

7

8

9

10

0 is No stress, 10 is Extreme stress
Main Sources of Stress
Exercise Frequency
Exercise - Type
Average Hours of Sleep
Sleep Quality
Special Diet

Other
Special Diet - Other
Water Intake
Caffeine
Alcohol
Tobacco/Nicotine Use
Recreational Drugs Use
Symptoms and TCM Notes
General Symptoms

Other
General Symptoms - Other
Head / Eyes / Ears / Nose / Throat Symptoms

Other
Cardiovascular Symptoms

Other
Respiratory Symptoms

Other
Digestive Symptoms

Other
Urinary Symptoms

Other
Musculoskeletal Symptoms

Other
Neurological & Emotional Health Symptoms

Other
Digestion, Bowel Movements, Urination, and Emotional State - TCM Notes
Women’s Health
Age at First Menstrual Period
Date of Last Menstrual Period

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cycle Length (days)
Menstrual Duration (days)
Menstrual / Women’s Health Symptoms

Other
Pregnancies / Births / Miscarriages / Abortions
Currently Pregnant?
Birth Control
Birth Control - Type
Energy, Temperature, and Practitioner Notes
Energy Level

0

1

2

3

4

5

6

7

8

9

10

0 is No energy, 10 is High energy
Temperature Preference
Sweating
Anything else for the practitioner
Spirituality, Values, and Personal Practices
Do you currently have a spiritual, religious, or personal contemplative practice?
If yes, please describe
Spiritual / personal practices

Other
How often do you engage in these practices?
How important is spirituality or your personal beliefs to you?
Beliefs we should be aware of
Practices that help you feel centered
Current spiritual, emotional, or life transitions
Anything else about your personal values, beliefs, or life purpose
Whole Person Wellness Reflection
Physical Health

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Energy & Vitality

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Sleep Quality

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Stress Management

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Emotional Well-being

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Mental Clarity & Focus

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Relationships

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Work or Daily Purpose

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Spiritual Connection

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Joy & Life Satisfaction

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Connection with Nature

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Overall Quality of Life

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Areas of health or life to improve
Greatest strengths or sources of support
What brings you peace, joy, or fulfillment
If your health improved over the next six months, what would you be able to do?
Anything else about you, your life, or your healing journey
Acknowledgment
Patient Signature
Acknowledgment Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

New Patient Health History - Qigong Healing and Chinese Medicine

Patient Information

Emergency Contact

Primary Concern and Treatment Goals

Diagnosis, Prior Care, and Pain

Medical History and Family History

Medications, Stress, Exercise, Sleep, Diet, and Habits

Symptoms and TCM Notes

Women’s Health

Energy, Temperature, and Practitioner Notes

Spirituality, Values, and Personal Practices

Whole Person Wellness Reflection

Acknowledgment