Health History Intake

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Welcome to Channel Acupuncture & Herbs, LLC, a holistic healthcare clinic focusing on acupuncture & natural healing arts.

Offerings include traditional Chinese acupuncture treatment along with Asian modalities that are used in combination with, or in lieu of acupuncture. These include moxibustion (herbal warming over points), cupping, gua sha (a vigorous rubbing technique along channels to disperse stagnation), auriculotherapy (placement of seeds or needles on the external ear) and electroacupuncture (calibrated electrical stimulation on needles).

Michelle Thelen, L.Ac. MSTOM is trained in nutrition and herbal medicine and is able to offer consultations with or without acupuncture treatment, when indicated.

Referrals are made to those patients who may need or require additional or alternative therapies. Michelle works hard to keep a list of ethical practitioners in allopathic and alternative medicine and she welcomes your personal referrals to aid towards the goal of advancing health and wellness.

Specialties of this office are: orofacial and jaw pain, women's health disorders, stress and anxiety disorders, orthopedic and musculoskeletal disorders, and immune-related imbalance. While Michelle has specialized training in the above-named disciplines she is also able to treat other health issues. Note that anxiety and stress are typically considered a part of treatment, as the mental-emotional state affects the body no matter what other problems may present.

This form includes specialized intakes for each of the above-named health issues, and you will be directed to the appropriate section based on your response. If any questions do not apply to you, please feel free to skip to the following question on the form.

Services are offered to any person regardless of sex, race, color, income, national origin, age, ability or disability, marital status, gender, familial situation, religion, size and shape, sexual orientation, veterans status, political beliefs or any differences of any kind. Adjustments in fees, as well as discounted services are available in certain circumstances.

Today's date *

YYYY

Date of Birth *

YYYY

Patient's Name (First Name, Last Name) *

If you are a parent of the named patient, completing this form for them, please provide your full name.

Street Address *

City, State, Zip Code *

Phone Number *

Is it okay to text you at this number to provide appointment reminders?

Yes

Clear selection

Email Address

Gender Identity

Female

Male

Non Binary

Height & Weight (Approximate is okay)

Employment *

Currently employed full time

Currently employed part time

Currently not employed

Retired

Have you had acupuncture before?

Yes

Clear selection

How did you hear about this practice?

Emergency Contact (Name & Phone Number) *

Please state the reason for your visit. Include chief complaint, any symptoms, and approximate date of onset of problem. Please limit response to one or two paragraphs. An interview will be conducted at your initial visit to make sure all relevant information is gathered. *

Are you experiencing pain? If so, please check the nature of the pain. If not please skip to the next question. Some descriptions are provided to help you choose. Note pain symptoms can overlap these categories. We will discuss in greater detail during your visit.

Musculoskeletal (often described as cramping, burning, or aching)

Neuropathic (often described as tingling, pins and needles, or sharp)

Joint (often described as deep, intermittent, swollen)

What self help measures or other treatments have you tried?

Do you have any allergies? If yes, please list and specify allergens such as foods, mold, dust, or you may also reply "seasonal" if allergens occur only with changing seasons.

Please list medications and supplements you have taken in the last 2 months.

Family & Self History. Please check all that apply.

Self

Family Member

Cancer

Diabetes

Mental or Emotional Illness (diagnosed)

Sexually Transmitted Disease

Heart Disease

Do you smoke?

Yes

Quit

Clear selection

Nutritional Status: Please describe your diet (vegetarian, omnivore, Paleo, etc.) and include any comments on alcohol and sugar intake.

Click all that apply.

Fatigue

Shortness of breath

Weight fluctuations

Hair loss

Appetite changes

Dizziness

Ringing in the ears

Bowel changes (ex. diarrhea, constipation, hemorrhoids)

Anxiety

Insomnia

Forgetfulness or memory problems

Urinary problems (ex. dribbling, frequent UTI's, urgency)

Pelvic pain

Depression

Blood pressure fluctuations (High or Low)

Heart rate or rhythm (rapid, slow, or skipped beats) or palpitations

Auto-immune disorder

Pain Survey (Skip to next question if this does not currently apply to you)

Acute/Sudden Onset

Chronic Pain (> 6 months)

Pain in neck and/or shoulders

Pain in arms and/or hands

Pain in back and/or spine

Pain in legs and/or ankle

Pain in foot

If you are interested in an herbal consult, please check the applicable option. (Note: herbal and nutritional consults are included with any acupuncture treatment) *

I have booked an acupuncture appointment and am open to herbal and nutritional recommendations

I have booked acupuncture services only

I have booked an herbal and nutritional consult only

Required

Please check only one response. If your reason for visit overlaps categories, choose the best response. We will go over any missing information during the initial interview.

Orofacial Pain

Women's Health

Facial Rejuvenation

I have listed my reason for visit on this form

Clear selection

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