Patient Forms

Patient Medical History

I am: SingleMarriedOther

Gender:FemaleMaleUnspecified

Are you pregnant?YesNo

What is the best way to communicate with you between office visits? (E-mail, Home, Work, Cell, Text).

Have you ever had Acupuncture before:
yesno

Are you interested in a treatment plan:
yesno

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Chief Complaint

What is your main issue that you would like to address:

Have you been given any MD’s diagnosis? If so, what?

What kind of treatments have you had? Results?

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Secondary Complaint

Significant Illnesses:
High Blood PressureDiabetesCancerThyroid DiseaseHeart DiseaseHepatitisSeizuresHIVOther

Major Operations and approximate dates:

Allergies:

Accidents/Significant Trauma:

Current medications taken (including drugs, vitamins, herbs & supplements):

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System Review

GENERAL:
poor appetiteweight gainnight sweatsInsomniaweight lossfeverdisturbed sleepchange in appetitechillslocalized weaknesssweating easilysudden energy dropcravingstremorspoor balancestrongthirstbleeding or bruising easily

Other unusual or abnormal conditions you have noticed in your general sense of health:

SKIN AND HAIR:
rasheseczemaulcerationspimpleshivesdandruffitchinghair loss

Any other hair or skin problems:

HEAD, EYES, EARS, NOSE, THROAT:
dizzinesscolor blindnessrecurrent sore throatconcussionscataractsnose bleedsmigrainesblurry visiongrinding teethglassesearachessores on lips or tonguespots in front of eyesringing in earsfacial paineye painpoor hearingteeth problemspoor visioneye strainheadachenight blindnesssinus problemsjaw clicks

Any other head of neck problems:

CARDIOVASCULAR:
dizzinesshigh blood pressureswelling of feetlow blood pressurefaintingblood clotschest paincold hands or feetdifficulty in breathingirregular heartbeatswelling of handsphlebitis

Any other heart or blood vessel problems:

RESPIRATORY:
coughbronchitisdifficulty breathingcoughing up bloodpain with deep inhalationasthmapneumoniaexcessive phlegm

Any other lung problems:

GASTROINTESTINAL:
nauseabelchingrectal painvomitingdiarrheablood in stoolsabdominal pain or crampsconstipationindigestionchronic laxative usegasbad breathacid refluxgerd

Any other problems with stomach or intestines:

GENITOURINARY:
pain on urinationurgency to urinatedecrease in flowfrequent urinationunable to hold urineimpotenceblood in urinekidney stonessores on genitals

Do you wake up at night to urinate?

If yes, how often?

Any particular color to your urine?

Any other genital or urinary problems

REPRODUCTIVE AND GYNECOLOGIC:
premenstrual changesheavy menstrual flowpremature birthsmenstrual clotslight menstrual flowmiscarriagespainful mensesirregular mensesabortionsunusual menses

The day of last menses:

MUSCULOSKELETAL:
neck painback painhand/wrist painsmuscle painsmuscle weaknessshoulder painsknee painfoot/ankle painship pain

Any other joint or bone problems:

NEUROPSYCHOLOGICAL:
seizurespoor memoryanxietydizzinesslack of coordinationbad temperloss of balanceconcussioneasily susceptible to stressareas of numbnessdepression

Have you ever been treated for emotional problems?

Have you ever considered or attempted suicide?

Any other neurological or psychological problems

COMMENTS:

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Signature
The scope of Acupuncture in the state of Florida and the modalities used at this clinic includes but is not limited to:
- Use of acupuncture needles to stimulate acupuncture points.
- Moxibustion – a herb placed on acupuncture needles to stimulate blood flow.
- Laser Therapy – K Laser or Class IV Laser therapy is used to stimulate endorphin release, manage pain, and increase healing potential to injuries.
- Micro-Current or electroacupuncture is applied to acupuncture needles which increases endomorphin, a natural opioid pain killer.
- Fire Cupping - suction cups are applied to areas of the body to alleviate tight muscles and to improve blood flow and circulation.
- Gua Sha or Dermal Friction Technique is used on the skin to stimulate blood flow and microcirculation of soft tissue.
- Chinese Herbal Medicine/Homeopathic Medicine/Nutrition
- Bodywork/Tui Na/Shiatsu/Trigger Point Therapy/Cranio-Sacral Therapy
- Injection Therapy (homeopathic, Vitamin B-12)
Possible Side Effects:
- Minor bleeding or bruising may occur as a result of acupuncture, cupping and related therapies.
Please check any items that apply to you:
Pacemaker

Other electrical implant

Bleeding Disorder

Anti-Coagulants (blood thinner) or other medications?

Have a damaged heart valve(s) or have any other particular risk of infection?

To Continue
Check Box below in Red.
Press “Proceed to Signature” at bottom of page.

Next Page
Scroll to bottom of page and click on “Sign Here”
Click “Draw” or “Type” Signature
Click “Adopt & Sign”
Lastly, “Agree & Sign”

This document will be sent to us electronically. No need to print unless for your own records.

I consent to having treatments and procedures from this clinic.

I release Dr. Tony Willcox PhD. and Acupuncture Zen Inc and its staff from any all claims incurred to me as a result of treatment. I understand that no statement made is intended as a medical diagnosis, nor is it considered as such. There is a no refund policy on all goods and services sold including oils, patches, herbal medicines, treatments, gift cards and packages at Acupuncture Zen Inc. I intend this consent form to cover the entire course of treatment for my present condition and further conditions for which I seek treatment. I confirm that I have read and understand the above information.

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Patient Forms

Patient Medical History

Chief Complaint

Secondary Complaint

System Review

Signature

Possible Side Effects:

Please check any items that apply to you: