New Patient Intake Form – Adam Moskow Acupuncture (954) 418-2287

Full Name *

Date of Birth

Age

Sex *

Male
Female

Determines which health sections appear below.

Height

Weight

Profession

Phone

Email *

Is it ok to text you appointment confirmations?

Emergency Contact Name

Relationship

Emergency Contact Phone

How did you hear about us?

Chief complaint #1 (most important to you) *

Chief complaint #2

Chief complaint #3

List all diagnoses given to you, in timeline sequence

List any medical procedures or surgeries you have had, in timeline sequence

What are you looking for in a healthcare practitioner?

What do you consider a realistic window of time to see changes in your health under our care?

On a scale of 1 to 10, how committed are you to recovering your health? Why?

What obstacles or beliefs, if any, stand in the way of you recovering your health?

Do you enjoy your work? Do you believe your work contributes to your health problems?

What are your special interests and passions?

Where else do you find support? Friends? Church or religious group? Nature?

How many times do you eat fish per week?

How many times do you work out per week?

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week

List the three healthiest foods you eat during the average week

Overall dietary pattern (e.g. standard American, paleo, keto, vegetarian, Mediterranean — or "I eat whatever")

Known food allergies or sensitivities

Daily water intake (approximate)

Do you skip meals? If so, which meals and how often?

Dairy consumption

None
Occasional
Daily

Gluten consumption

None
Occasional
Daily

Medications — list each with dose and what it is for (one per line)

Supplements — list each with dose and what it is for (one per line)

Blood work / imaging — how will you share them?

Online file upload is not available on this form. Please email recent blood work or imaging to adam@adammoskow.com, or bring copies to your visit.

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas *

Alternating constipation and diarrhea *

Diarrhea *

Constipation *

Hard, dry, or small stool *

Coated tongue or “fuzzy” debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body *

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movements *

Sense of fullness during and after meals *

Difficulty digesting proteins and meats; undigested food found in stools *

Stomach pain, burning, or aching 1-4 hours after eating *

Use of antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward *

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation *

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Difficulty digesting roughage and fiber *

Indigestion and fullness last 2-4 hours after eating *

Pain, tenderness, soreness on left side under rib cage *

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucus like, greasy, or poorly formed *

Frequent loss of appetite *

Abdominal distention after consumption of fiber, starches, and sugar *

Abdominal distention after certain probiotic or natural supplements *

Decreased gastrointestinal motility, constipation *

Increased gastrointestinal motility, diarrhea *

Alternating constipation and diarrhea *

Suspicion of nutritional malabsorption *

Frequent use of antacid medication *

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome? *

Greasy or high-fat foods cause distress *

Lower bowel gas and/or bloating several hours after eating *

Bitter metallic taste in mouth, especially in the morning *

Burpy, fishy taste after consuming fish oils *

Unexplained itchy skin *

Yellowish cast to eyes *

Stool color alternates from clay colored to normal brown *

Reddened skin, especially palms *

Dry or flaky skin and/or hair *

History of gallbladder attacks or stones *

Have you had your gallbladder removed? *

Acne and unhealthy skin *

Excessive hair loss *

Overall sense of bloating *

Bodily swelling for no reason *

Hormone imbalances *

Weight gain *

Poor bowel function *

Excessively foul-smelling sweat *

Crave sweets during the day *

Irritable if meals are missed *

Depend on coffee to keep going/get started *

Get light-headed if meals are missed *

Eating relieves fatigue *

Feel shaky, jittery, or have tremors *

Agitated, easily upset, nervous *

Poor memory, forgetful between meals *

Blurred vision *

Fatigue after meals *

Crave sweets during the day *

Eating sweets does not relieve cravings for sugar *

Must have sweets after meals *

Waist girth is equal or larger than hip girth *

Frequent urination *

Increased thirst and appetite *

Difficulty losing weight *

Cannot stay asleep *

Crave salt *

Slow starter in the morning *

Afternoon fatigue *

Dizziness when standing up quickly *

Afternoon headaches *

Headaches with exertion or stress *

Weak nails *

Cannot fall asleep *

Perspire easily *

Under a high amount of stress *

Weight gain when under stress *

Wake up tired even after 6 or more hours of sleep *

Excessive perspiration or perspiration with little or no activity *

Edema and swelling in ankles and wrists *

Muscle cramping *

Poor muscle endurance *

Frequent urination *

Frequent thirst *

Crave salt *

Abnormal sweating from minimal activity *

Alteration in bowel regularity *

Inability to hold breath for long periods *

Shallow, rapid breathing *

Tired/sluggish *

Feel cold — hands, feet, all over *

Require excessive amounts of sleep to function properly *

Increase in weight even with low-calorie diet *

Gain weight easily *

Difficult, infrequent bowel movements *

Depression/lack of motivation *

Morning headaches that wear off as the day progresses *

Outer third of eyebrow thins *

Thinning of hair on scalp, face, or genitals, or excessive hair loss *

Dryness of skin and/or scalp *

Mental sluggishness *

Heart palpitations *

Inward trembling *

Increased pulse even at rest *

Nervous and emotional *

Insomnia *

Night sweats *

Difficulty gaining weight *

Urination difficulty or dribbling *

Frequent urination *

Pain inside of legs or heels *

Feeling of incomplete bowel emptying *

Leg twitching at night *

Decreased libido *

Decreased number of spontaneous morning erections *

Decreased fullness of erections *

Difficulty maintaining morning erections *

Spells of mental fatigue *

Inability to concentrate *

Episodes of depression *

Muscle soreness *

Decreased physical stamina *

Unexplained weight gain *

Increase in fat distribution around chest and hips *

Sweating attacks *

More emotional than in the past *

Pain and cramping during periods *

Scanty blood flow *

Heavy blood flow *

Breast pain and swelling during menses *

Pelvic pain during menses *

Irritable and depressed during menses *

Acne *

Facial hair growth *

Hair loss/thinning *

Perimenopausal *

Alternating menstrual cycle lengths *

Extended menstrual cycle (greater than 32 days) *

Shortened menstrual cycle (less than 24 days) *

Hot flashes *

Mental fogginess *

Disinterest in sex *

Mood swings *

Depression *

Painful intercourse *

Shrinking breasts *

Facial hair growth *

Acne *

Increased vaginal pain, dryness, or itching *

Since menopause, do you ever have uterine bleeding?

How many years have you been menopausal?

Cancellation Policy Acknowledgement *

I understand there is a 24-hour cancellation policy at this office and there will be a fee charged to my credit card if I cancel within a 24-hour timeframe of my scheduled appointment or don’t show up.

Type your full name as signature *

Date *

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