Bubbling Spring Wellness
10605 Concord St., Suite 410 Kensington, MD 20895
301-613-4449 

NEW PATIENT INFORMATION

NAME __________________________________________ Date ________________________

Address ______________________________________________________________________

City ____________________________________________ State __________ Zip __________

Day Phone #__________________________ Evening Phone # __________________________

Cell Phone #__________________________ E-mail Address ___________________________

Date of Birth _________________________ Age ____ Sex ____ Height ____ Weight ________

Social Security # __________________________________________ Marital Status M S D W

Driver's License # ___________________________________ State Issued ________________

Referred by _______________________________________ Phone # ____________________

EMPLOYER ______________________________________ Phone # ____________________

Address ______________________________________________________________________

City ____________________________________________ State __________ Zip __________

Occupation _____________________________________________ How long ______________

Name of Spouse _______________________________________________________________

Spouse's employer _____________________________________________________________

Address ______________________________________________________________________

City ____________________________________________ State __________ Zip __________

Number of Children: Boys _____ Ages _______ Girls _____ Ages _______

In case of emergency, contact: __________________________________________________

Address ______________________________________________________________________

City ____________________________________________ State __________ Zip __________

Day Phone ___________________________ Evening Phone ___________________________

Cell Phone ___________________________ E-mail Address ___________________________

My insurance company covers acupuncture treatment. Yes No (If yes, fill in Ins. Info)

Insurance Company ______________________________ Phone # (____) _________________

Address ______________________________________________________________________

City ____________________________________________ State __________ Zip __________

ID # ______________________________________ Group # ___________________________

Name of insured _______________________________________________________________

Social Security # of Insured _______________________________________________________

PATIENT HEALTH QUESTIONNAIRE

Present Health Complaint(s) Indicate Treatment & Results

1____________________________________________________________________________

2____________________________________________________________________________

3____________________________________________________________________________

4____________________________________________________________________________

When were you last seen by a physician? ___________________________________________

For what purpose? _____________________________________________________________

Doctor's name ______________________________________ Specialty __________________

Address ______________________________________________________________________

City _____________________________ State____ Zip __________ Phone # ______________

Diagnosis by your doctor: ________________________________________________________

List lab work completed:
_____________________________________________________________________________
_____________________________________________________________________________

List current medications: Indicate response to medication

1.___________________________________ _____________________________________

2.___________________________________ _____________________________________

3,___________________________________ _____________________________________

4. __________________________________ ______________________________________

Current supplements or over-the-counter items Indicate response to supplements

1.___________________________________ _____________________________________

2.___________________________________ _____________________________________

3,___________________________________ _____________________________________

4.___________________________________ ______________________________________

Circle the items that you use? Indicate how much and how often?
Coffee _______________________________________________________________________
Tea _________________________________________________________________________
Alcohol ______________________________________________________________________
Chocolate ____________________________________________________________________
Cigarettes ____________________________________________________________________
Laxatives _____________________________________________________________________
Sugar ________________________________________________________________________
Artificial Sweeteners ____________________________________________________________

List foods that you crave _________________________________________________________
_____________________________________________________________________________

List known allergies to either food or drugs: __________________________________________
_____________________________________________________________________________

Describe any special dietary restrictions: ____________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Are you able to work without problems? If no, describe. ________________________________
_____________________________________________________________________________

How often do you feel fatigue? ____________________________________________________

What time of day are you the most tired? _____________________________________________

Do you experience undue worry, difficulty concentrating or forgetfulness? If yes, describe.
_____________________________________________________________________________

Have you had any significant accidents, injuries or illnesses? Describe: ____________________
_____________________________________________________________________________

List any other hospitalizations or surgeries you have had, and your age at the time:
_____________________________________________________________________________

Do you have a pacemaker? _______________________________________________________

Did you have any of the following childhood diseases? 
Measles  Mumps  Chicken pox  Frequent Ear Infections  Rashes  Mono

List any unusual childhood illnesses: ________________________________________________
______________________________________________________________________________

Is your mother still alive? Yes No If not, age at death? ________________

What was the cause of death? ______________________________________________________

Is your father still alive? Yes No If not, age at death? ________________

What was the cause of death? ______________________________________________________

If any of your siblings have died, please give their ages and the cause of death: _____________
______________________________________________________________________________

FAMILY HISTORY: Check all conditions that have affected your parents, grandparents, siblings & children

CONDITION Relatives/s Affected CONDITION Relatives/s Affected
Addiction(s) ______________________ Genetic Disease _______________________
Allergies ______________________ Gout _______________________
Arthritis ______________________ Headache/Migraine _______________________
Asthma ______________________ Heart Disease _______________________
Bladder/Kidney ______________________ High Blood Pressure _______________________
Bleeding Issues ______________________ Lung Issues _______________________
Cancer ______________________ Overweight _______________________
Depression ______________________ Stroke _______________________
Diabetes ______________________ Thyroid Disease _______________________
Digestive ______________________ Intestinal Issues _______________________
Suicidal/Suicide ______________________

YOUR HISTORY: Check all of the conditions that you have now or ever have had.

__Alcoholism __Emphysema/Asthma __Muscle Problems Thyroid:Hypo__ Hyper__
__Arthritis __Epilepsy/Seizures __Neurological Issue __TMJ/Jaw Dysfunction
__Anxiety/Depression __Eye Issues __Psychological Issues __Herpes __CMV
__Autoimmune Disease __Genetic Condition __Respiratory Issues __Polio __Mono
__Bladder/Kidney __Headaches __Rheumatic Fever __Weight Loss:
__Cancer __Heart Disease __Scarlet Fever

How much ___Time?____

__Digestive Issues __High Blood Pressure __Sexually Trans Dis. __Weight Gain:
__Diabetes __HIV/AIDS __Sinus/Upper Resp.

How much___ Time?____

__Ear Infections/Issues __Hormonal Issues __Stroke __Other:_______________
__Eczema/Skin Issues __Intestinal Issues __Swallowing Issues ______________________

 

Exams Last Completed Physical _______ Results: ____________ By whom? ______________
  Homocult (blood in stool) ______ Results: ____________ By whom? ______________
  Last Sigmoidoscopy of colon ___ Results: ____________ By whom? ______________
Females Last Menses ____ Menopause Y N # of Pregnancies _____ # of Children __ Pregnant Y N
  Last Mammogram __________ Results: ____________ Breast Self-Exam Y N
  Last Pap Smear ____________ Results: ____________  
  Last Breast Exam ___________ Results: ____________  
Males Last Prostate Exam _________ Results: ____________ Prostatitis Y N Urinary Freq. Y N
Children Learning Issues Y N Poor Attention Span Y N Hyperactivity Y N

 

ACTIVITY LEVEL: STRESSES AFFECTING YOUR LIFE:
__Sedentary (inactive) by choice __Difficulties with work or lifestyle
__Sedentary (inactive) due to inability or restriction __Recent change in marital status
__Light: light daily work w/no regular exercise __Death or serious illness of family or friend
__Moderate: light daily work and exercise 3X/week __Dysfunctional family __Past __Present
__Sustained: moderate daily work & exercise 5X/week __Lack of love or fulfilling relationship(s)
__Sustained: moderate daily work & exercise 5X/week __Illness - self

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Bubbling Spring Wellness, 10605 Concord St., Suite 410Ave., Kensington, MD 20895
phone 301-613-4449