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Patient Information
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Scot Somes, LAc.
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Steph Somes, LAc.
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Practitioner you are seeing
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First Name*
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Last Name*
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Date
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Address*
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City*
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State*
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Zip*
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Living Status
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Date of Birth (xx/xx/xxxx)*
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Primary Phone (xxx.xxx.xxxx)*
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Secondary Phone
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Employment Type
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email*
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Gender
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Employer/Occupation*
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Referred By
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Emergency Contact and Phone
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Contact Number
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Physician
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May we contact them?
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Have you had Acupuncture before?
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Who and what for?
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Are you presently under a doctor's care?
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Are there any other therapies you are involved with?
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If so, what therapies
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Insurance Information(fill out all fields only if United Healthcare or Aetna is your provider)
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Insurance Plan Name:
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Front of Card:
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Back of Card:
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Insurance phone number for providers:
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AETNA
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Insured Member ID #:
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Insurance Address:
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UHC
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Insured Group #:
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Payer ID #:
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Employer
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Relationship
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Policy holder's name:
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Focus
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Primary reason for seeking care:*
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What was the initial cause?
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When did it begin?
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What makes it worse?
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What makes it better?
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How does it affect daily activities?
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Work
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Standing
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Sexually
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Sleep
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Emotional
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Recreational
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Walking
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Relationships
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Bending
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Sitting
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Social Life
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Stretching
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What have you done for this?
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Are you interested in:
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Pain Relief
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Herbal Therapy
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Performance
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Prevention
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Maintenance
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Other
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Oriental
Nutrition
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Stress Relief
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What are your health goals?
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List any past or future surgeries:
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List any significant trauma and
when:
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List exercise and sports activities:
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Signs/Symptoms
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Sudden energy
drop
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Ab pain/distention
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Constipation
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Frequent urination
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Kidney stones
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Poor appetite
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Limited range
of motion
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Abuse survivor
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Cough
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Gas/belching
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Poor circulation
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Swollen glands
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Acid reflux
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Coughing blood
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Grinding teeth
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Loss of hair
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Poor memory
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Teeth/gum issues
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Acne
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Dark stools
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Headache
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Low back pain
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Poor sleep
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Ulcerations
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Premature
ejaculation
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Asthma
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Decreased libido
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Hemorrhoids
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Migraine
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Upper back pain
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Bad Breath
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Depression
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Heart palpitations
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Mouth sores
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Psoriasis
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Urgent urination
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Blood in stools
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Dizziness/vertigo
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Hiccup
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Mucous in stools
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Rash
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Vomiting
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Muscle
cramps/pain
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Blood in urine
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Dry mouth/throat
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High blood pressure
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Red eyes
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Wake to urinate
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Blurry vision
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Diarrhea
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Impotence
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Nasal congestion
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Seizures
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Weight loss
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Neck/shoulder
pain
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Breast lump/pain
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Ear aches
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Seeing therapist
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Weight gain
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Increased libido
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Shortness of
breath
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Bruise easily
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Enlarged thyroid
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Indigestion
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Night sweats
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Wheezing
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Nocturnal
emission
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Chest pain
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Eye issues
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Intestinal pain
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Sinus pressure
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Chills
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Excessive phlegm
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Irritable
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Nose bleeds
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Skin fungus
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Colds hands/feet
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Excessive saliva
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Itchy eyes
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Numbness
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Spots in eyes
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Concussion
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Fatigue
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Itchy skin
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Odorous stools
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Sweat easily
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Confusion
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Fever
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Joint pain
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Pain with
urination
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Sore throat
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Female Concerns
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Is your cycle regular?
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Date of last menstruation
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Have you been pregnant?
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Is your cycle painful?
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Birth control?
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How long?
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History
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If so, what?
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Do you have allergies?
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Do you take medication?
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If so, what?
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If so, what?
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Do you take supplements?
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Please indicate if you or
any family members have
or had any of the
following conditions:
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Pneumonia
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Drug reaction
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Mental breakdown
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STD
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Mental illness
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Tuberculosis
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Heart attack
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Jaundice
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HIV/Aids
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Hypothyroid
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High/Low blood
pressure
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Hepatitis
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Blood transfusion
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Parasites
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Hyperthyroid
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Premature
graying
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Diabetes
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Anemia
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Measles
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Heart disease
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Epilepsy
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Arthritis
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Mumps
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Gout
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Seizures
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Kidney Stones
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Obesity
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Syphilis
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Cancer
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MS
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Do you sleep well?
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Do you dream?
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What are your indulgences?
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What are your hobbies/pleasures?
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Areas of Pain
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Please indicate areas you are experiencing pain and the pain level
(N/A, 1 very little to 10 extreme)
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Neck
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Forearm
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Sciatic
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Calves
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Upper Back
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Wrist
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Hamstrings
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Ankles
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Shoulders
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Hand
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Thighs
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Feet:
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Arms
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Mid back
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Hips
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Toes
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Elbows
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Low back
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Knees
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Plantar area
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Please elaborate on areas of pain
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Terms of Acceptance
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Please read the following agreements, initial in the boxes to the left and
click the submit button to send form to the office. By clicking the submit
button you have agreed to all terms and conditions on the forms.
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Please read the Consent to Treat Agreement by clicking on the link.
Initial in the box to the left indicating you have read and understand the Consent to Treat
Agreement.
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Initials*
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Please read the Mandatory Disclosure Document by clicking on the link for the practitioner you are
seeing:
Scot Somes, LAc. Stephanie Somes, LAc.
Initial in the box to the left indicating you have read and understand the Mandatory Disclosure
Document.
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Initials*
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Notice of Privacy
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