SPAULDING REHABILITATION HOSPITAL NETWORK

AMBULATORY SERVICES

INTEGRATIVE HEALTH SERVICES

REGISTRATION FORM

Today’s Date:

Name
Emergency Contact Phone #
How did you hear about our  E-mail  Referring Physician  Website/Search Engine
integrative Programs?  Family/Friend (name) (name)  YouTube
 Other

 Social Media
 Print/Flyer
Have you ever been a patient of Spaulding Rehabilitation Hospital? (Circle One): Yes No
Appointment Type  Acupuncture  EFT  Myofascial Release
 Biofeedback  Massage  Reiki
 Craniosacral Therapy  Meditation  Yoga

What are the symptoms/problems for which you are seeking treatment?

What are Your Treatment Goals?

Have you received a diagnosis for your concerns? If yes, what was the diagnosis?

What kinds of treatment(s) have you tried or are currently using related to these concerns?

If there is pain, please describe the pain (i.e., pins and needles; burning; stabbing; deep ache, etc.)

Please use the diagram below to indicate the symptoms you have experienced.

Please mark the severity of your chief concern TODAY.

No problem Worst imaginable
1 2 3 4 5 6 7 8 9 10

Please mark the severity of your chief concern AT ITS WORST.

No problem Worst imaginable
1 2 3 4 5 6 7 8 9 10

Please mark the severity of your chief concern AT ITS BEST.

No problem Worst imaginable
1 2 3 4 5 6 7 8 9 10

PLEASE COMPLETE BOTH SIDES

Medical History Please mark all that apply.
GENERAL
 Fevers/Chills  Change in Appetite  Seizures/Tremors  Sudden energy drops?
 Peculiar tastes or smells  Fatigue  Day/Night Sweats What time of Day?
 Cancer  Poor Sleep/ Insomnia  Weight Loss/Gain  Emotional Changes
 Dream Disturbed Sleep  Bleeding or Bruising  Strong thirst for hot/ cold drinks  Poor Appetite

CARDIOVASCULAR
 High/Low blood pressure  Swelling of Hands  Blood Clots  Irregular heartbeat
 Difficulty in Breathing  Palpitations  Cold Sweats  Cold Hands/Feet
 Chest pain  Swelling of Feet  Phlebitis

GASTROINTESTINAL
 Nausea/Vomiting  Abdominal Pain/ Cramps  Digestive Disorders  Parasites
 Constipation/Diarrhea  Indigestion  Belching  Ulcers
 Bad Breath  Blood in Stools  Hernia  Hemorrhoids

GENITO-URINARY
 Pain on Urination  Decrease in Urine  Kidney stones  Urgent Urination
 Blood in Urine  Waking up to Urinate  Frequent Urination  Impotency/ Infertility
 Incontinence How often?  HSV (Herpes Simples Virus)  Prostate Problems
 Erectile Dysfunction Rashes/Itching  Discharge  Low Sperm Count

MUSCULOSKELETAL
 Muscular Weakness/Spasms  Arthritis  Recent Sprains  Muscle Cramps
 Injuries or Falls  Muscular Atrophy  General Aches  Joint Pain/Instability
NEUROPSYCHOLOGICAL
 Seizures  Areas of Numbness  Concussion  Lack of Coordination
 Poor Memory  Dizziness/Fainting  Loss of/Poor Balance  Depression/Anxiety
 Migraines/Headaches  Disorientation  Mania/Easily Angered  Susceptible to Stress

PREGNANCY & GYNECOLOGY

Age at First Menses Number of Pregnancies  Birth Control? Yes No  Heavy or Irregular
Period between Menses Number of Births What type?  Clots
Duration of Menses Miscarriages How long?  Light
 Fertility Problems Abortions  Vaginal Discharge  PMS
 Difficult Births  Breast Lumps  Painful Periods

RESPIRATORY
 Cough  Pain w/ Deep Breaths  Easily Winded w/ Exertion  Asthma
 Bronchitis  Shortness of Breath  Difficulty in Breathing when laying down
 Coughing Blood  Production of phlegm What Color? _______________

Please give us any details regarding hospitalizations:

Please give us any details regarding surgeries:

Please give us any details regarding significant traumas:

Please Mark Any of The Following That Apply

Antacids Currently Occasionally Herbs Currently Occasionally

Antihistamines Currently Occasionally Ibuprofen Currently Occasionally
Aspirin Currently Occasionally Laxatives Currently Occasionally
Blood Thinners Currently Occasionally Oral contraceptives Currently Occasionally
Cardiac Medications Currently Occasionally Sleeping pills Currently Occasionally
Cold tablets Currently Occasionally Tranquilizers Currently Occasionally
Diet pills Currently Occasionally Vitamins Currently Occasionally

I hereby authorize the above mentioned Integrative Services to be provided by the Spaulding Rehabilitation Hospital Network Clinicians. I know the practice of
medicine is not an exact science and I acknowledge that no guarantees have been made to me to as to the result of treatment(s) or examinations. If I experience
any pain or discomfort during treatment, I will immediately inform the practitioner, so treatment can be adjusted. I affirm that I have stated all known medical
conditions and answered all questions honestly. I realize that the Integrative Medicine Service is a self-pay program and I will provide payment at the time of
visit.

Signature_________________________________________________________ Date
PLEASE COMPLETE BOTH SIDES