General information
Full Name
DOB
Occupation
Cell phone
Email
Address
Any diagnosed disease
Medications
Supplements
Any surgeries
Please list two major health issues that you’d like me to help with:
Issues
Issue list 1
Issue list 2
Time of first started
Time of first started 1
Time of first started 2
Any therapies tried (please list)
therapies tried1
therapies tried 2
Any medication or supplements tried (please list)
medication or supplements tried 1
medication or supplements tried 2
Triggering factors
Triggering factors 1
Triggering factors 2
Your diet
Please let me know about your diet (if you eat less then 3 meals, just put N/A on the 3rd meal session)
1st meal
Time
Content
2nd meal
Time
Content
3rd Meal
Time
Content
Other meals
Time
Content
Snacks
Time
Content
Water intake
Time
Content
Other liquid
Time
Content
Bedtime
Time
Content
Wake up time
Time
Content
Exercise (how often, what kinds)
Time
Content
Bowel Movement per day
Time
Content
Symptoms
Stressed out
Score
Depression
Score
Anxiety
Score
insomnia
Score
Sleep Apnea
Score
Memory loss
Score
Brain fog
Score
Fatigue
Score
Attention deficient
Score
Mood swings
Score
Bloating or cramps or pain in the stomach
Score
Heart burn
Score
Gassy
Score
Frequent or painful urination
Score
Cough
Score
Shortness of breath
Score
Palpitation
Score
Muscular and/or skeleton pains
Score
Hot flashes
Score
Night sweats
Score
Woman’s Health
Do you have regular menstrual cycle (Y/N)
Content
1st day of last period
Content
How many pregnancy
Content
How many kids
How many kids content
How old is your youngest child
Content
Any BCP or hormonal IUD in your whole life (Y/N)
Content
Any hormonal treatment in your whole life (fertility, HRT or hormone blocker)
Content
Are you currently on BCP or hormonal IUD, if yes, please indicate what kind
Content
Are you currently on any hormonal treatment, if yes, please indicate what kind
Content
PMS (0: none; 10: strong)
Content
Libido (0: none; 10: normal )
Content
Your relationships
How do you rate your workplace relationships (0: very bad; 10: very good)
Score
Do you think your workplace relationship affects your health (Y/N)
Score
How do you rate your household relationships (0: very bad; 10: very good)
Score
Do you think your household relationship affects your health (Y/N)
Score
Are your health concerns caused by an emotional trauma (Y/N)
Score
Other information
Do you contact chemicals at work? (Y/N)
If yes, what are they
Score
Do you drink tap water? (Y/N) If yes, how much per day
Score
Did your house have water damage before (Y/N)
Score
Is your house near major high way
Score
Is your hobby involving contacting chemicals, if yes, what kind
Score
Were you naturally born or through C-session
Score
Were you breast fed
Score
How many rounds of antibiotics have you had in your whole life
Score
Most recent TSH
Score
Most recent HbA1C
Score
Consent for Functional & Nutritional Medicine Evaluation and/or Treatment
acceptance1
I understand that if I cannot arrive for my scheduled appointment, I am required to notify the clinic 48 hours in advance. If I did not provide a notice 48 hours before my scheduled appointment, I agree to pay the amount of the missed appointment.
By signing this, I hereby authorize Hong Yan to provide recommendations with accordance to the principles of Functional and nutritional medicine. I understand that Hong Yan does her best to provide appropriate guidance and recommendations but make no guarantee of the results. I understand that she does not provide primary care services and the guidance received does not substitute the need for primary care services and medical treatments (including but not limited to drugs or surgery). I understand that Functional and Nutritional medicine, as well as services provided to me at Southcentre Chinese Acupuncture are not intended to diagnose, or fully cure any medical condition, do not follow the standard of care guidelines, and do not substitute medical care by a physician or another primary care provider. I hereby understand that I am responsibly for consulting with my physician or a primary care provider. I understand that the treatment recommendations, sessions, herbs, nutritional guidance, labs, and supplements may not be covered by health insurance plan and that I am responsible for payment of any services and products received from Southcentre Chinese Acupuncture.
Signature of patient*
Signature of patient*
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