This questionnaire is an essential component of successful diagnosis and treatment. Please
answer all questions carefully.
Name ____________________________ Date ____________ Age ____________ Gender ___________
List your five main complaints below, in order of importance:
Number of Years
1. _______________________________________________
______________
2. _______________________________________________
______________
3. _______________________________________________
______________
4. _______________________________________________
______________
5. _______________________________________________
______________
Check if you have taken frequent:
____ Antibiotics
____ Antihistamines
____ Sedatives
____ Hormones
____ Birth Control Pills
____ Bronchial Inhalers
____ Cortisone
____ Nose Drops or Sprays
____ Skin Ointments
____ Vitamins
____ Antidepressants
Please list below all drugs, vitamins, herbs or
homeopathic remedies you are currently taking:
(use back of sheet if necessary)
Is there a family history of:
Diabetes ___ Cardio-Vascular Disease____ Allergies_____ Asthma____ Cancer____
Are you allergic to any foods or medications? If so, which? ________________________
Have you ever been hospitalized for a:
Medical problem
no________
Surgical procedure
no________
Psychiatric reason
no________
yes________
yes________
yes________
If yes, list reasons for hospitalization, treatment & date of stay: (use back of sheet if necessary)
1
Name ________________________________
Body Systems Review (please check all that apply):
0 = never
1 = rarely
2 = occasionally
3 = frequently
4 = always
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
low appetite
loose stools
mouth sores
abdominal gas/bloating after food
gums (bleeding/swollen)
organ prolapsed (diagnosed)
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
ravenous appetite
heartburn/acid reflux
fatigue after eating
bruise easily
thirst
belching or vomiting
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
spontaneous sweat
allergies
asthma
general weakness
dry nose/mouth/skin/throat
feel worse after exercise
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
fatigue
catch colds easily
shortness of breath
cough
nasal discharge
sinus congestion
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
sore, cold or weak knees
low back pain
frequent urination
early morning diarrhea
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
feel cold
edema
urinary incontinence
ear problems
yes
yes
no impaired memory
no infertility
high
yes
normal
no hair loss
low libido
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
muscle spasms/twitches
feel better after exercise
tight feeling in chest
alternating diarrhea/constipation
symptoms worse with stress
neck/shoulder tension
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
irritable
numb extremities
dry eyes
ear ringing
anger easily
red eyes
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
feel heart beating
insomnia
sores on tip of tongue
anxiety
chest pain traveling to shoulder
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
chest pain
disturbing dreams
headaches
restlessness
4
4
4
4
4
foggy thinking
dizzy upon standing
nausea
night sweats
cloudy urine
high
high
0
0
0
0
0
0
1
1
1
1
1
1
normal
normal
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
low
low
see floaters in eyes
heat in palms or soles
feeling of heaviness
afternoon fever
enlarged lymph nodes
face flushes
overall body temperature
overall energy level
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
2
Name ________________________________
Urination:
Please circle any of the following symptoms you are currently experiencing:
Burning
Urgent
Retention
Profuse
Dribbling
Bowel Movements: Frequency: _______
Scanty
Greater than 1x a night
When? _________
Feels complete? Yes No
Please circle any of the following symptoms you are currently experiencing:
Stools:
Undigested food
Consistency: Well-formed
Blood
Mucus
Hard
Loose
Alternates
*****************************************************************************
Men Only:
Have you been diagnosed with prostate problems? ☐ Yes ☐ No ☐
Do you experience premature ejaculation?
Do you have problems with Impotence?
Have you been diagnosed with Infertility?
☐ Yes
☐ Yes
☐ Yes
☐ No
☐ No
☐ No
Diseases/ Disorders:_____________________________________________________________
Women Only:
Fertility History
Are you pregnant now? ☐ Yes ☐ No
Have you been pregnant in the past? ☐Yes ☐ No
Number of live births ____ Miscarriage ___ Abortion____
Infertility work-up (if pertinent)
Doctor or clinic ______________________________ When? _______________________
Do we have your permission to correspond with your reproductive specialist? ☐Yes ☐No
What tests (HSG, hormone levels, Blood work) and findings?______________________________
_____________________________________________________________________________
Current medications (Clomid, Lupron) and treatment plan?________________________________
_____________________________________________________________________________
3
Name_________________________________
Menstrual History
At what age did you get your first period: _______ Date of last menstrual cycle? ________
Are you currently on the Pill or other medical birth control therapy? ☐ Yes ☐ No
Number of days from the start of one period to the start of the next: ___________________
Are your menstrual cycles spaced regularly? ☐Yes ☐ No Average number days of flow: _______
Maximum Flow Day:
Use of tampon or pad is
Normal = change every 3 hours
Maximum Flow Day: Color is
Light = use one for longer than 4 hours
Heavy = change every hour or less
Pink
Red
Dark
Heavy with clots
Bright Red
Does your period cause you pain or cramping? ☐No Yes: ☐ Before ☐ During
☐ Brown
☐ After Period
Do you get nausea or vomiting with your period? ☐ No Yes: ☐ Before ☐ During ☐ After Period
Do you experience any of the following before your period each month?
☐ Water retention
☐ Breast tenderness or swelling ☐ Mental depression
☐ Food cravings
☐ Migraines
☐ Irritability
☐ Other________________
Do you ever bleed or spot between periods? ☐ Yes ☐ No
Do your bowel movements become loose at the beginning of your period? ☐ Yes
Do you have any vaginal discharge between periods? ☐ Yes
☐ No
☐ No
Gynecological Problems
Date of last pap smear? _____________Have you ever had an abnormal pap smear? ☐Yes ☐ No
Any gynecological surgery? ☐ No ☐ Yes, when: __________________
Have you ever had a venereal disease or PID? ☐ No
☐ Yes: __________________
Do you get yeast infections regularly? ☐ Yes ☐ No
Have you ever been diagnosed with uterine fibroids or polyps? ☐ Yes ☐ No
Have you ever been diagnosed with ovarian cyst or PCOS? ☐ Yes
☐ No
Have you ever been diagnosed with endometriosis? ☐ Yes ☐No
Have you been diagnosed pelvic adhesions abnormalities?
☐ Yes
☐ No
Menopause
Have you experienced menopause? ☐ Yes
☐ No
Are you on HRT or herbal aids now? ☐ Yes ☐ No
When? ______________________
What? ______________________
If you are experiencing menopausal symptoms, please describe: _______________________
4
Name __________________________________
Lifestyle/habits
List what you typically eat for the following meals:
Breakfast:
Lunch:
Dinner:
Snacks:
Do you skip meals?
Breakfast ______ Lunch ______ Dinner ______
Do you drink caffeinated beverages?
No ______
Yes ______
Coffee ______ (cups/day) Tea ______
Soda ______
Do you drink alcohol?
No ______
Yes ______
What? ____________________________ How often? __________________
Do you eat fish ______
chicken ______ meat ______
eggs ______
dairy products ______
Do you eat fruit? ______
Which?
How often?
___________________________________________________________
___________________________________________________________
Do you eat vegetables? ______
Which?
How often?
___________________________________________________________
___________________________________________________________
How much water do you drink? ______________________________
Do you eat sweets (cake candy, ice cream, cookies, etc.)?
No ______________
Yes ______
What? ___________________________ How often? _____________________
Do you have or have you had an eating disorder?
No __________________
Yes ______
Anorexia ______
Bulimia ______
Do you exercise?
No ______
Yes ______
How often? _________________________________What type of exercise?
How many hours do you typically sleep? ______________
What time do you typically go to bed? ______ Arise? ______
Do you have trouble falling asleep? ______
staying asleep? ______
Do you have nightmares? ______
Do you use sleep medication?
No ______
Yes ______
What kind ____________________________________
How often ____________________________________
5
Name _______________________________
Do you ______ smoke marijuana?
______ use cocaine?
______ heroin?
______ other drugs?
What kind? _________________________________________
Do you smoke cigarettes? No ______
Yes ______
How much? ______
For how long? ______
Have you ever tried to quit before? ______
What means? ________________________
Longest time cigarette free _____________
What kind of work do you do?
Is the work stressful for you? _____________
Is there stress in other areas of your life (home, family, relationships)?
Medical/Psych Care
Who is your personal physician?
Name:
Address:
Phone:
Do you regularly see any specialists? (Gyn, GI, ENT, GU, etc.)
Name:
Name:
Address:
Address:
Phone:
Phone:
Do you get chiropractic, osteopathic, physical therapy or massage treatment? If so, which one(s)?
Are you now or have you been in
______ psychotherapy?
______ group therapy?
______ 12 step program?
Do you regularly meditate or participate in spiritual practice?
Have you ever had acupuncture before?
No ______
Yes ______
When and with whom?
Do you have experience with western or Chinese herbal treatment?
6
Patient Information & Treatment Consent Form
I hereby request and consent to the performance of acupuncture treatments and other Oriental medicine procedures on me (or on the patient
named below, for whom I am legally responsible) by any authorized Turning Point Acupuncture practitioner. I understand that methods or
treatments may include but are not limited to acupuncture, moxibustion, cupping, bloodletting, electrical stimulation, Tui Na (Chinese
massage), Gua Sha, tai chi, yoga, qi gong exercise, Chinese or Western herbal medicine, and nutritional counseling. I have been informed
that acupuncture is considered a safe method of treatment, but that it may have side effects including bruising, numbness or tingling near
the needle site, which may last a few days. An unusual risk of acupuncture includes spontaneous miscarriage, nerve damage and organ
puncture. Infection is another possible risk, however since this practice uses only sterilized, single-use, disposable needles while
maintaining a clean and safe environment, this is unlikely. Burns and scarring are potential risks of moxibustion.
The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally
considered safe in the practice of Chinese Medicine. I understand the same herbs may be inappropriate during pregnancy and will inform
my practitioner immediately of pregnancy status. If I experience any gastro-intestinal reactions to the herbs I will inform the acupuncturist
immediately.
I have been informed that I have a right to refuse any form of treatment. I have read, or have had read to me the above consent. I have also
had an opportunity to ask questions about its content, and by signing below I agree to the above- named procedures. I also understand there
is always a possibility of an unexpected complication and I understand that no guarantee can be made concerning the results of treatment. I
intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek
treatment.
________initials
I understand it may be necessary for my practitioner to contact another one of my health care providers in order to coordinate medical
treatment, to discuss an emergency situation and/or to share appropriate medical information. My signature gives my practitioner
permission to release my medical records for the reasons listed above.
________initials
Acupuncture has been practiced for thousands of years and is considered a safe procedure. It is unlikely but possible that you might
experience the following: Minor, transient discomfort can occur as the pins penetrate the skin. Numbness, tingling or a sensation of heat
or pulling may occur during the treatment. All of these sensations are normal. It is extremely rare for a serious medical incident to result
from acupuncture. The most common untoward effects of the treatment include, but are not limited to, these: Occasionally, the acupoint
will bleed slightly when the needle is withdrawn. Bruising from minor bleeding under the skin are infrequent, but do happen. Transient
lightheadedness can occur as the body's energy (Qi) changes, but passes rapidly. With regard to treatment outcome, usually symptoms are
reduced with treatment. If they are unchanged, more or different treatment is needed. Uncommonly, a symptom will get worse after the
treatment as energy (qi) moves through an area of blockage. Thereafter, once the energy moves freely, relief can be significant.
Please let the practitioner know if you are pregnant, or trying to get pregnant, as this will influence the placement of the needles.
Fees and Billing for Acupuncture services:
$200.00 Initial consultation and treatment (Please allow 1 ½ hours for the visit)
$100.00 Regular visits (Please allow one hour)
The fees for herbs/supplements are additional when recommended. Please pay for your treatment at each visit. Insurance or flex-spending
reimbursement may be available depending on your carrier's polices.
Our cancellation policy: If it is necessary for you to cancel, please give us 24 HOURS NOTICE. If you cancel with less notice, you will
be charged full visit fee. Your full cooperation is appreciated.
Initial Appointment: Schedule your appointment carefully, at a time convenient for you. A credit card will be necessary to secure your
initial appointment time.
WE, THE UNDERSIGNED, DO AFFIRM THAT (THE PATIENT) HAS BEEN ADVISED BY, (A LICENSED
ACUPUNCTURIST), TO CONSULT A PHYSICIAN REGARDING THE CONDITION OR CONDITIONS FOR WHICH
SUCH PATIENT SEEKS ACUPUNCTURE TREATMENT.
___________________________
________________________
(Patient Signature)
Date
___________________________
________________________
(Practitioner Signature)
Date
Signed consent for treatment:
I have read the above information, agree to the terms therein and agree to treatment.
Name:_________________________________________________ Date: ________________
7
Patient Profile
Please Print
Name (Last, First):
Street Address:
City, State, Zip:
Email Address:
This information will permit your acupuncturist to communicate with you by email.
You will also receive our informative quarterly newsletter. If you prefer, opt out by checking here. 
Home Phone :
Work Phone:
Cell Phone:
Current age:___________
Birth date:
Place of Birth (City, State, Country):
Time (include AM or PM):
Social Security Number:
Emergency Contact (Name and Phone Number):
Please tell us how you heard about Turning Point Acupuncture so we may acknowledge them:
___________ Google
___________ Other Internet Resource (specify)
___________ Referred by an Organization (specify)
___________ Referred by a Person
Referrer’s Name and (if known), Address: ____________________________
____________________________
____________________________
____________________________
8
9
Notice of Privacy Policies
Dear Patient,
Health care providers have always protected the confidentiality of health information by
locking medical records away in filing cabinets and refusing to reveal your health
information. Here at Turning Point Acupuncture we have always taken precautions to
ensure confidentially of this sensitive information.
With the onset of the electronic age, the federal government published regulations
designed to further protect the privacy of your health information. This “privacy rule”
protects health information that is maintained by physicians, hospitals, other health
providers, and health plans. As of April 14, 2003, all health care providers will be
required to comply with these privacy standards to protect the confidentiality of your
heath information. This includes paper records, oral communications and electronic
formats (such as email) and the electronic submission of medical insurance forms.
As specifically concerns privacy at Turning Point, we never release any information
about a patient unless permission is first obtained from the patient. This includes phone
or written inquiries from insurance companies, law firms or other interested parties.
Please know that every time you sign an insurance claim form you give your insurance
provider permission to obtain information from the practitioner listed on the form.
With regard to email, the practitioners at Turning Point will use your email address to
communicate with you by request, after office hours and for patients in distant locations.
The clinical director sends an electronic medical newsletter approximately quarterly.
Anyone can opt to be removed from that mailing list.
I hope this clarifies our privacy policies. If you have further questions please feel free to
contact the office.
Thank you,
E. Shane Hoffman, DAOM, LAc
Clinical Director
21 June 2010
I have read and understand the Notice of Privacy.
Name (signature): ________________________________
Date: __________________________________________
10