Submit the completed form to Oregon State University Student Health Services at SHS @ Dixon, 211 Dixon Recreation Center, Oregon State University, Corvallis, Oregon 97331. You can also submit it via email to studenthealth@oregonstate.edu or fax it to 541-737-7721. Make sure to include all necessary information and sign the form before submission.

No specific dates for this form are provided for 2024 and 2025.

The purpose of this form is to gather comprehensive health information from students seeking acupuncture treatment at Oregon State University. It allows the acupuncturist to understand the patient's medical history, current health conditions, and any treatments they are undergoing. This information is essential for providing safe and effective acupuncture care tailored to the individual's needs. The form includes sections on personal information, major complaints, and personal health history. Patients are asked to provide details about their general health, any specific conditions they have, and treatments they are currently receiving. The form also includes a section on family health history, which can be important for identifying potential hereditary conditions. By collecting this information, the acupuncturist can make informed decisions about the patient's treatment plan. This ensures that any potential risks are identified and managed, and that the treatment is as effective as possible. It also helps to build a comprehensive health record for the student, which can be valuable for ongoing care and treatment.

• 1. Patient Information: Includes fields for the patient's name, address, contact information, personal details such as height, weight, sex, marital status, date of birth, age, and occupation.
• 2. Major Complaint: Asks the patient to describe the primary reason for their visit, any diagnoses by other providers, current treatments, and their effectiveness.
• 3. Personal Health History: Includes questions about the patient's general health as a child, any significant illnesses or conditions they have had, and current health issues.
• 4. Family History: Asks about any illnesses that have occurred in the patient's blood relatives, such as alcoholism, allergies, cancer, diabetes, heart disease, and more.
• 5. Women Only: Includes questions specifically for female patients, such as pregnancy status, birth control methods, menstrual history, and any related health issues.
• 6. Men Only: Includes questions specifically for male patients, such as libido, impotence, vasectomy, and any related health issues.

If you fail to submit this form, it may delay or prevent you from receiving acupuncture treatment at Oregon State University's Student Health Services. The acupuncturist would lack the necessary information to provide safe and effective treatment.

• Delayed Treatment: Without the form, the acupuncturist may not be able to proceed with your treatment promptly.
• Incomplete Health Records: Your health records may be incomplete, which could impact future treatments and care.
• Increased Risk: Lack of essential health information could increase the risk of adverse reactions during treatment.

• 1. Before Acupuncture Treatment: Complete this form before your first acupuncture session to provide the necessary health information to your acupuncturist.
• 2. Updating Health Records: Use this form to update your health records if there are any significant changes in your health status.
• 3. Chronic Conditions: If you have a chronic condition, use this form to document your medical history and any ongoing treatments.
• 4. Family Health History: Provide information about your family health history to help identify potential hereditary conditions.
• 5. Pre-treatment Assessment: This form allows the acupuncturist to assess your overall health and tailor the treatment plan to your specific needs.