Bubbling Spring Wellness
3930 Knowles Ave., Suite 301 Kensington, MD 20895
301-587-1177

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

Bubbling Spring Wellness, 3930 Knowles Ave., Suite 301 Kensington, MD 20895
phone 301-587-1177  e-mail: acudan@mindspring.com