NEW PATIENT INTAKE FORM

LILY CHOI NATURAL HEALING

120 W 58TH ST, SUITE 7D, NEW YORK, NY 10019 || info@lilychoinaturalhealing.com
Name

First NameLast Name
Email
example@example.com
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
DOB
For Virtual Appointment, How Can I Reach You?

FaceTimeWhatsAppSkype
For Virtual Appointment, Number/ Email To Reach You
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Marital Status
Education (Highest grade or degree achieved)
How did you hear about our clinic?
Have you been treated by acupuncture or Oriental medicine before?
Name of your physician

First NameLast Name
Phone of your physician
Address of your physician

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In an emergency please notify:

Full namePhone number
MAIN COMPLAINT AND PRESENT MEDICAL HISTORY
1. What is the reason you are here and what is the main problem you are seeking help with?
2. How long ago did this problem begin?
3. Have you been given a diagnosis for this problem? If so, what?
4. What kinds of treatment have you tried?
5. Are you currently receiving treatment for your problem If so, please describe
6. Does anything improve your problem?
PAST MEDICAL HISTORY
Illnesses
Surgeries
Any significant trauma? (Auto accidents, falls, etc)
Do you have, or have you ever had any infectious disease?

YesNo
If Yes, please describe
Do you have, or have you ever had any sexually transmitted disease?

YesNo
If Yes, please describe
Do you suffer from any allergies?
All medicines (including prescription and over the counter drugs, recreational drugs, vitamins, herbs, etc.) taken within the last three months
FAMILY MEDICAL HISTORY (GENERAL HEALTH)
Mother's side
Father's side
If any of the above is deceased, what was the cause?
PERSONAL HISTORY
Birth history (prolonged labor, forceps, delivery, etc)
Childhood health
Location of upbringing (geographically prone to certain diseases, habits, etc.)
Current emotional health
Current quality of life
Current relationship/quality
Current predominant emotion
Stress level
Recent stresses? Have you had any unusual stress as of late?
Favorite time of year
Least favorite time of year
Hobbies & recreational habits
Do you have a regular exercise program?

YesNo
If yes, please describe
Have you traveled abroad in the past year?

YesNo
If yes, please describe
Do you drink alcohol?

YesNo
Do you smoke?

YesNo
If applicable, please describe your alcohol or smoking intake
NEUROPSYCHOLOGICAL (Check all that apply)

SeizuresDisorientationConcussionPoor MemoryAnxietyFaintingHeadacheMigrainesDepressionMemoryLack of coordinationEasily angeredManiaDizzinessAreas of numbnessEasily stressed
Have you ever been treated for emotional problems?
Have you ever considered or attempted suicide?
Any other neurological or psychological problems?
Any nervous habits?
GYNECOLOGY
PREGNANCY

MiscarriagesAbortionsDifficult birthsBreast LumpsClots
Number of pregnancies
Number of births
MENSTRUAL HEALTH
Age of first menses
Period between menses
Duration of menses
Period type, mark all that apply

Unusual characterHeavyLightIrregular periods
Birth Control? Y/N What type and how long?
First Date of Last Menstrual Cycle

MonthDayYear
Date
Date of Last Pap Smear

MonthDayYear
Date
Do you experience changes in body and/or psyche prior to menstruation?
PLEASE MARK ALL THAT APPLY AND WHICH YOU HAVE EXPERIENCED IN THE LAST 3 MONTHS
GENERAL:

FeversChillsFatigueTremorsChange in appetiteSeizuresSudden energy dropsPoor sleep/insomniaStrong thirst for hot drinksStrong thirst for cold drinksDream disturbed sleepPoor balanceJoint painHeadachesWeight gainCold sweatsDay sweatingManiaPoor appetiteDepressionBleeding or bruisesWeight lossLocalized weaknessEmotional changes
CARDIOVASCULAR:

Swelling of handsCold hands/feetHigh Blood pressureBlood clotsFaintingDifficulty breathingPhlebitisLow Blood pressurePalpitationsShortness of breathIrregular heartbeatChest painDizzinessOther
RESPIRATORY:

CoughAsthmaDifficulty breathingEasily winded w/ exception of laying downCoughing bloodShortness of breathBronchititsOther
Production of phlegm and color?
GASTROINTESTINAL:

NauseaVomittingIndigestionAbdominal pain/crampsBelchingUlcersHerniaBad breathHemorrhoidsDigestive disordersParasitesDiarrheaConstipationBlood in stoolOther
GENTIO-URINARY:

Pain on urinationUrgent urinationBlood in urineImpotency/ infertilityGenital soresFrequent urinationUnable to hold urineDecrease in urineKidney stonesOther
Waking up to urinate? How often?
MUSCULOSKELETAL:

Muscular weaknessMuscle crampsInjuries or fallsGeneral achesArthritisMuscular atrophyJoint instabilityRecent sprainsPain with deep breathsSpasmsGeneral achesOther
Please use the scale below to tell us how intense your pain is

1

2

3

4

5

6

7

8

9

10

1 is No pain, 10 is Most pain
Are there any other internal organ or systemic dysfunctions that we should be aware of? Are there any other problems you would like to discuss?
CONSENT FOR ACUPUNCTURE/TREATMENT
I, name understand acupuncture treatment to involve the use of needles, acupressure, moxibustion and electrical stimulation etc. The risks, although limited, include: puncturing organs in the abdomen or chest cavities. Acupuncture may affect people on all levels: physical, emotional, mental and spiritual, because it works with the whole body to create balance. The duration of treatment varies from person to person depending on the specific illness and their constitution. I fully understand that there is no stated or implied guarantee of success or effectiveness after a specific treatment or a series of treatments.
Patient's signature (Parent or Guardian's signature if under 18)

Clear
Date

MonthDayYear
Date
CANCELLATION POLICY
All fees for services are due at the time of each appointment unless you purchased special treatment packages (in which case you had prepaid for several treatments during your first visit). I accept cash, check, or credit card (VISA, MASTERCARD, AMEX).

Your appointment time is reserved especially for you. I encourage that you keep the appointment so that we can continue working towards your optimum health. If, however, you cannot make the appointment time, or need to reschedule, please do so within 24 hours before your appointment. You can do so through the online scheduling system, or you can call, text, or email me.

The fee for late cancellation (less than 24 hours) is the full amount of your visit, unless you reschedule for another time within a week of your previous appointment. I appreciate your understanding and cooperation.
Patients signature (Parent or Guardian's signature if under 18)

Clear
FOOD DIARY
Typical Breakfast Choices
Typical After Breakfast Snack Choices
Typical Lunch Choices
Typical After Lunch Snack Choices
Typical Dinner Choices
Typical After Dinner Snack Choices
All the different drinks you have throughout the day, including how much water
List all the Vitamins & Supplements previously or currently taking
Should be Empty:

LILY CHOI NATURAL HEALING

MAIN COMPLAINT AND PRESENT MEDICAL HISTORY

PAST MEDICAL HISTORY

FAMILY MEDICAL HISTORY (GENERAL HEALTH)

PERSONAL HISTORY

GYNECOLOGY

MENSTRUAL HEALTH

PLEASE MARK ALL THAT APPLY AND WHICH YOU HAVE EXPERIENCED IN THE LAST 3 MONTHS

CONSENT FOR ACUPUNCTURE/TREATMENT

CANCELLATION POLICY

FOOD DIARY