Thank you for considering Synoma Wellness Centre as the next stop on your road to improved health.  
 
We consider our time with you extremely valuable. Like you, we prefer to focus on “you” during our sessions. Therefore, we sincerely appreciate your assistance with completing the necessary paperwork prior to our first visit. Thus, we are enclosing the following and ask that you present a completed set to us upon your first visit:
 
•	Patient Health History 
•	Acknowledgement of Receipt of Notice of Privacy 
•	Consent to treat
•	Cancellation Policy
 
Having these forms completed upon your first visit will only enhance the quality of our time together. It is also very beneficial for you to bring with you any supplements, vitamins and/or herbs that you are currently taking. If you are visiting us for acupuncture, you should make sure that you eat a high quality protein meal approximately one hour before your visit. It is also advisable that you wear comfortable clothing.

If you are unable to keep your appointment, we ask that you call us at least 24 hours in advance to reschedule. Our office is conveniently located at 1755 Wisconsin Ave. Palm Harbor FL 34683.

Again, thank you for the opportunity to assist you with your health status. Please do not hesitate to call us should you have any questions. It would also be greatly appreciated if you would send a return e-mail with the completed paperwork prior to your appointment. Thank you!
 
Sincerely,
 
Dr. Tammi A. Jones, DOM
Email: drtammij@synomawellnesscentre.com
Website: www.PalmHarborAcupuncture.com

Patient Health History

Personal Information                                                           				                         Date___________
Name____________________________________________________________  Age______   Date of Birth____________
Parents Name (if minor)_________________________________________________________________________
Address_________________________________________________  City_________________    State____    Zip________
Phone: Home __________________________      Work________________________       Cell_______________________
E-mail _____________________________________ 
I prefer to be contacted at: (circle one)  Home   Work    Cell     E-mail 
Social Security # ____________________________ 
Drivers License # _______________________________________ 
Occupation______________________________          
Employer ______________________________________________
In case of emergency, call:  Name __________________________________________          Phone __________________
Ht ___________   Wt___________  Sex (M) (F)    Marital Status ______________   
Children (ages)_________________
How did you hear about us? ___________________________________________________________________________

Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally and emotionally.  Please complete this questionnaire as thoroughly as possible.  Print all information and indicate areas of confusion with a question mark.  Thank You! 

When and Where did you last receive health care?_______________________________
For what reason?__________________________________________________________
Please identify the health concerns that have brought you to Synoma Wellness Centre, in order of importance, below:

         Condition/ Chief Complaint                                     Past Treatment                          
      1.___________________________________________________________________                                  2.___________________________________________________________________                         3.___________________________________________________________________     
      4.___________________________________________________________________     
If applicable, please list any Allergies or Hypersensitivities you might have (foods, drugs or medications, environmental substances): ________________________________________________________________________
Please list any medications (prescribed and over-the counter) vitamins, and supplements you are currently taking and why:____________________________________________________________________________________________________________________________________________
________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Have you recently stopped taking any medications? If so what and why?  ________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Do you  have any reason to believe you  are pregnant? ____________________________ 
If so how far along are you?_________________________________________________
Do you have any infectious diseases?  Y / N  If yes, please identify: _____________________________________

Immunizations (please circle any that you have had):
Polio      Tetanus      Rubella/Mumps      Pertussis      Diphtheria      Hib       Hepatitis B    Others: ______________

Childhood Illness : (please circle any that you have had):
Scarlet Fever      Diphtheria        Rheumatic Fever      Mumps        Measles         German Measles         Chicken Pox 
Other Frequent Childhood Illness: ____________________________________________
BloodPressure:   High/Normal/Low 
What is your most recent blood pressure reading? _____ /_____    
When was this reading taken? _______________
Cholesterol Levels: High/Normal/Low  Readings: HDL____________LDL___________Triglycerides_________
Has your Doctor suggested any medication for elevated levels?____________________

Hospitalizations and Surgeries: 

When             Reason                                                   When              Reason                                                
1.   ____________________________________   4. ________________________________
2.   _____________________________________ 5. ________________________________
3.   _____________________________________ 6. ________________________________
Rays/ CAT Scans/ MRI’s/ NMR’s/ Special Studies:

    When          Reason                                                   When              Reason                                                    
1.   ___________________________________    4. __________________________________
2.   ___________________________________    5. __________________________________
3.	_____________________________________   6. __________________________________

Emotional  (please circle any that you have now and underline any that you have experienced in the past):   
	Mood Swings         Nervousness            Mental Tension             Depression                Anxiety

Energy and Immunity  (please circle any that you  have now and underline any that you have experienced in the past):  
         Fatigue          Slow Healing Wounds        Frequent Infections             Chronic Fatigue Syndrome
Head, Eye, Ear, Nose and Throat (please circle any that you have now and underline any that you have experienced in the past):
Impaired Vision      Eye Pain/Strain       Glaucoma         Glasses/Contacts        Tearing/Dryness
Impaired Hearing    Ear  Ringing           Earaches           Headaches                  Sinus Problems
Nose Bleeds            TMJ                        Hay Fever         Teeth grinding            Frequent Sore Throats                     Jaw Problems         
Respiratory (please circle any that you have now and underline any that you have experienced in the past):
	Pneumonia               Pleurisy                  Tuberculosis      Frequent Common Colds
	Emphysema             Persistent Cough      Asthma             Difficulty breathing                                                 	Shortness of Breath
Other Respiratory Problems: ________________________________________________________

Cardiovascular  (please circle any that you experience now and underline any that you have experienced in the past):
	Heart Disease          Chest Pain                Rheumatic Fever		Swelling of the Ankles
	Palpitations              Fluttering                 Stroke			Varicose Veins         
	High Blood Pressure
Gastrointestinal (please circle any that you experience now and underline any that you have experienced in the past):
Ulcers                      Nausea/Vomiting      Belching           Change in Appetite       Liver Disease
Epigastric Pain         Passing gas               Heartburn         Gall Bladder Disease    Hepatitis B or C                     
Hemorrhoids            Abdominal Pain

Urinary Tract  ( please circle any that you have now and underline any that you have experienced in the past):
Kidney Disease        Painful urination            Frequent UTI        Frequent Urination       Heavy Flow
Kidney Stones          Impaired Urination          Blood in Urine       Frequent Urination at Night

Female Reproductive/ Breasts (please circle any that you have now and underline any that you have experienced in the past ):
Irregular Cycles           Breast Lumps/ Tenderness           Nipple Discharge          Heavy Flow
Vaginal Discharge       Premenstrual  Problems               Clotting                         Bleeding between Cycles
Painful Periods             Menopausal Symptoms               Cramps                          Infertility
Date of Last Mammogram: _______ Results: Normal / Abnormal (Explain) _______________________
History of Ovarian Cysts/ Uterine Problems/ Fibroids/ Other: __________________________________

Menstrual/ Birthing History: 
  1.Age of First Menses ______6. Birth Control Type _______  9. # of Abortions _______
2.# of Days of Menses ______ 7. # of Pregnancies:     ______10. # of Live Births______
3.  Length of Cycle: ________ 8. # of Miscarriages: ______11. Date of Last Menses____
4.  Date of last Pap Smear ______ Results: Normal/ Abnormal (Explain) ________________________________________________________________________
Menopause: Pre____   Post____       Problems: _________________________________ 

Male Reproductive (please circle any that you experience now and underline any that you have experienced in the past ):
Sexual Difficulties       Prostate Problems         Testicular Pain/ Swelling        Penile Discharge

Musculoskeltal (please circle any that you experience now and underline any that you have experienced in the past ):
Neck / Shoulder Pain    Muscle Spasms/ Cramps    Arm Pain          Upper Back Pain    Mid Back Pain
Low Back Pain              Leg Pain                             Joint Pain (if so where?):____________________

Neurologic (please circle any that you experience now and underline any that you have experienced in the past):
Vertigo/ Dizziness         Paralysis          Numbness/ Tingling       Loss of Balance         Seizures/ Epilepsy

Endocrine  (please circle any that you are experiencing now and underline any that you have experienced in the past ):
Hypothyriod                 Hypoglycemia         Hyperthyriod        Diabetes Mellitus      Night Sweats   
Feeling Hot  or Cold

Other (please circle any that you experience  now and underline any that you have experienced in the  past ):
Anemia        Cancer      Rashes          Eczema/ Hives        Cold Hands/ Feet

FAMILY HISTORY (Please list family health problems)

Mother__________________________________________________________________

Father__________________________________________________________________

Brothers/Sisters___________________________________________________________

Grandparents ___________________________________________________________

GENERAL HEALTH  PRACTICES
Smoking: 
Do you  smoke now? _____ If so, how much per day? _______Did you ever smoke? _____________
If so, how much for how long? _____When did you quit? _________________________

Teeth:  
Do you have any Metal fillings? ______ Any root  canals? _____ Use Fluoride toothpaste? __________

Exposures: 
Are you exposed to pesticides/ chemicals at home or  work?________________________________

Allergies:  Do you have any environmental allergies? If so What? _____________________________________

Sleep: How many hours do you sleep at night? ____________ Do you wake up rested? ____________________ 
Do you sleep through the night? ________ Do you have any sleeping problems? _________________________

Exercise: How often do you  exercise? ___ times per week   ____ minutes per day– Type __________________

Stress:  Do you  feel like you are under stress? If so, explain briefly ___________________________________

Bowels: How often do your bowels eliminate? _______times per day _____times per week. Other ___________
Describe typical bowel movement: Loose & Easy to pass / Hard & Difficult to pass / Frequent  Diarrhea

Urination: Is your Urination normal? _____ Scanty or Profuse? Frequent Night time Urination? Y / N 
If so how many times do you go at night? ____________

History of  Yeast Infections? _____ History of Frequent Antibiotic use? __________

What is your energy like? _____Low  _____Medium  _____ High
On a scale of 1 to 10, how do you feel? (10= best,, 1 = worst) _________

Have you had anything surgically removed? If so what & when? _________________________________
Have you experienced any major Traumas?__________________________________________________

Nutrition

How many meals do you eat in a typical day?______ Do you follow a specific diet? If so which one
_____________________________________________________________________________________

How many servings per day of: Protein______Vegetables_________Fruits________Bread_________
                                                    Pasta/Rice/Potatoes_______Dairy_________Sweets/Sugar_________
How much water do you drink per day?_____________Type: Filtered/ Tap/ Bottled
How many caffeinated beverages per day?_________Coffee_______Tea________Other:__________
How many Soft Drinks do you have daily?___________Weekly?_______

Alcohol use: (circle one) Daily   Weekly   Monthly   Rarely   Never   Other:_______________________
Do you use artificial sweeteners?  Yes/No   Which ones?______________________________________
Do you snack during the day?________If so, on what?________________________________________
Do you have any food cravings?______________If so, what do you crave?_______________________
Do you have any food allergies?_______If so, which foods are you allergic too?___________________

Please list foods eaten on your typical diet:
Breakfast:____________________________________________________________________________
Lunch:_______________________________________________________________________________
Dinner:_______________________________________________________________________________

Please label  all PROBLEM AREAS  as  1,3,OR,5. (1=MILD, 3=MODERATE, 5=SEVERE)
___ Lack of Energy             ___ Headaches                        ___ High Blood Pressure
___ Backaches                     ___Weight Problems             ___ Low Blood Pressure
___ Heart burn                     ___ Low Sex Drive                ___ Frequent Infections
___ Poor Circulation            ___ Cold Hands and Feet      ___ Diabetes
___ Food Allergies               ___ Hypoglycemia                ___ Sinus infections
___ Gas, Bloating                 ___ Water Retention             ___ Environmental Allergies
___ Diarrhea                         ___ Constipation                   ___ Painful  Joints
___ Irritability                      ___ Depression                      ___ Loss of Memory
___ Depression                     ___ Anxiety                          ___ Osteoporosis
___ Menstrual Problems       ___ Menopause Problems     ___ Prostate Problems
___ Rashes/ Skin Problems  ___ Irregular Heartbeat          ___ Asthma
___ Sleep Problems              ___ Hemorrhoids                   ___ Yeast Infections 
___ Cancer                            ___ Spasms/ Cramps             ___ Pain– If so Where? __________

Any comments or concerns:_______________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

I HAVE READ  THE ABOVE  INFORMATION AND CERTIFY IT TO BE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

DATE_____________PATIENTS SIGNATURE: ______________________________
                                                                         (parents signature if patient is a minor)

REFERRED BY: ________________________________________________________
                                                                                        
Tammi A. Jones, Acupuncture Physician
Synoma Wellness Centre
727.953.6620
drtammij@synomawellnesscentre.com