HEALTH HISTORY QUESTIONNAIRE

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1 300 N. Willson Ave, Suite 3002 Bozeman, MT (406) HEALTH HISTORY QUESTIONNAIRE Name: DOB: Age: Height: Weight: Address: City: State: Zip: Phone: Cell: Emergency Contact: Phone: Occupation: Marital Status Have you ever tried acupuncture before: YES NO Are you sensitive to needles? YES NO Who may we thank for referring you? Recent Health Care Providers: (Name, Date, Service provided) Insurance Provider: Policy # WHAT IS YOUR MAIN CONCERN? When did you first notice symptoms? How does this affect your daily activities? Do you have a western medical diagnosis? Hospitalizations/Surgeries/Accidents? Allergies: FAMILY HEALTH HISTORY Family Member Age Disease/Illnesses Deceased Y/N

2 PERSONAL HEALTH HISTORY Please list all medicines, herbs and supplements that you are currently taking or have taken in the past month. Include dosages and frequency. Attach a separate sheet of paper if necessary: GENERAL Please check all that apply below Poor Appetite Weight Gain Weight Loss Cravings Insomnia Night sweats Disturbed Sleep Poor Balance Sudden energy drop Fever Chills Tremors Strong thirst Sweating easily Bleeding Bruising SKIN & HAIR Rashes Eczema Psoriasis Hives Itching Ulcerations Pimples Recent moles Hair loss Dandruff Changes in hair texture HEAD, EYES, EARS, NOSE & THROAT Dizziness Concussion Migraines Glasses Spots in front of eyes Eye pain Poor vision Cataracts Photophobia Night blindness Color blindness Blurry vision Eye strain Ringing in ears Ear aches Ear discharge Poor hearing Headaches Sinus problems TMJ Nose bleeds Recurrent sore throat Grinding teeth Teeth problems Facial pain Jaw clicks Bleeding gums Dry lips Sores on lips or tongue

3 CARDIOVASCULAR High blood pressure Low blood pressure Dizziness Chest pain Fainting Irregular heart beat Chest tightness Palpitations Blood clots Phlebitis Stroke Swelling of hands Swelling of feet Cold hands/feet Difficulty breathing RESPIRATORY Cough Asthma Bronchitis Emphysema COPD Shortness of breath Excessive phlegm Frequent colds Flu History of smoking Coughing up blood GASTROINTESTINAL Nausea Vomiting Diarrhea Parasites Belching Rectal pain Constipation Gas/bloating Acid reflux Bad breath Hemorrhoids Indigestion Black stools Abdominal cramps Blood in stools Crohn s Colitis Diverticulitis History of polyps IBS Chronic laxative use Tender abdomen Sudden change in bowel movements GENITOURINARY Pain on urination Incontinence Sores on genitals Decreased flow Urinary infections Blood in urine Kidney stones Impotence Low to no sex drive Wake at night to urinate Vaginal/Penile discharge MUSCULOSKELETAL Neck pain Back pain Hand/wrist pain Knee pain Shoulder pain Muscle pain Muscle weakness Sciatica Hip pain Foot/ankle pain Arthritis Tinnitus Migraines Numbness/tingling Varicose veins Jaw pain

4 NEUROPSYCHOLOGICAL Seizure Poor memory Anxiety Depression Bad temper Loss of balance Concussion Mood swings OTHER ILLNESSES & BLOODBORNE PATHOGENS HIV positive Rheumatic fever Eating disorder Jaundice AIDS Mononucleosis Diabetes Epstein-Barr Hepatitis Underweight Overweight Hypoglycemia MENTAL HEALTH Is stress a major problem for you? YES NO Do you feel depressed? YES NO Do you panic when stressed? YES NO Do you cry frequently? YES NO Do you have problems with eating or appetite? YES NO Have you ever attempted suicide? YES NO Have you ever seriously thought about hurting yourself? YES NO Do you experience alcohol or drug addiction or dependance? YES NO Have you ever been to a counselor? YES NO Would you like a referral for a counselor? YES NO WOMEN S HEALTH Age at onset of menstruation: Date of last menstruation: Cycle occurs every days Number of pregnancies: Number of live births: Are you pregnant or breastfeeding? YES NO D&C, hysterectomy, or Cesarean? YES NO History of miscarriages or abortions? YES NO Hot flashes or night sweating? YES NO Heavy periods, irregularity, spotting, pain or discharge? YES NO Menstrual tension, pain, bloating, irritability or PMS around cycle? YES NO Breast tenderness, lumps, nipple discharge? YES NO

5 MEN S HEALTH Recent kidney, bladder or prostate infections? YES NO Problems emptying your bladder completely? YES NO Difficulty with erection or ejaculation? YES NO Testicle pain or swelling? YES NO BPH or chronic prostatitis? YES NO Burning or discharge from penis? YES NO LIFESTYLE EXERCISE: Sedentary (no exercise) Mild (climb stairs, walk a few blocks, golf) Occasional vigorous exercise (workout, recreation, less than 4X/week for 30 minutes) Regular vigorous exercise (workout or recreation 4X/week or more for at least 30 minutes) DIET: Are you dieting? YES NO If so, are you on a physician prescribed medical diet? YES NO Number of meals you eat in an average day? Please describe your daily diet (what is an average meal for you, do you avoid any foods?) CAFFEINE: Indicate # of cups/cans per day Coffee Tea Soda TOBACCO: YES NO Type? # per day # of years? ALCOHOL/DRUGS: Do you drink alcohol? YES NO How many drinks per week? Do you use recreations drugs? If yes, what type and how often?

6 Please mark painful or distressed areas on the chart above PAIN X = little XX = moderate XXX = severe SWELLING O = slight OO = moderate OOO = severe WEAKNESS W = slight WW = moderate WWW = severe NUMBNESS N = slight NN = moderate NNN - severe SKIN ISSUES = S Temperature = ( + hot ) ( - cold ) Please use the space below to list any other information that you think is important regarding your health history and general intake:

7 300 N. Willson Ave, Suite 3002 Bozeman, MT (406) VITALITY ACUPUNCTURE CLINIC POLICIES I agree to provide at least 24 hours notice of a cancellation and accept the $40.00 fee for missed appointments. I acknowledge that there is a $35.00 processing fee for returned checks. Acknowledgement of the receipt of Vitality Acupuncture clinic policies Vitality Acupuncture, LLC., provides each patient with a statement of clinic policies. Initial: I have read, revised, understand and agree to the statement of the Office Policies for healthcare services at Vitality Acupuncture. Acknowledgement of the receipt of Vitality Acupuncture Consent to Privacy Practices Name (printed) Signature Date If you are a minor or you are being represented by another party Personal Representative (printed) Signature Date Description of the authority action on behalf of the patient:

8 This form is required by our malpractice insurance company. Please read and sign. Thank you. ACUPUNCTURE INFORMED CONSENT Consent I, hereby authorize Valerie Schwankl, Licensed Acupuncturist, to perform acupuncture treatments on me (or on the patient named below, for whom I am legally responsible). This authority shall extend to remedying any unforeseen conditions or reactions to treatment procedures. Scope of Practice I understand that scope of practice includes, but is not limited to, the following: Using Oriental medical theory to assess, diagnose, and develop a plan to treat a patient in an attempt to improve overall body function and/or to relieve pain. Using treatment techniques that may include: -Insertion of sterile acupuncture needles through the skin -Acupuncture stimulation including, but not limited to electrical stimulation or the application of heat with moxabustion or heat lamps -Cupping -Dermal friction -Acupressure -Herbal therapies -Dietary counseling based on traditional Chinese medical principles -Breathing techniques or exercise according to Oriental medical principles Risks and Possible Side Effects I understand that there are possible side effects to my treatment that may include the following: Minor pain or soreness in the treatment area Transient bruising Infection Needle sickness (dizziness, nausea, fainting) Broken needles Sensations of heat, cold, tingling or numbness Skin irritation or slight bleeding at needle site Generalized fatigue Gastrointestinal disturbance from herbal remedies Minor burns from moxabustion (heat stimulation) Spontaneous miscarriage Pneumothorax Treatment Outcomes I understand that no promises or guarantees can be made regarding the outcome of treatment and that reasonable efforts will be made to give me information so that I might make educated decisions regarding the duration and appropriateness of continued care. I understand that I may stop treatment at any time. Western Biomedical Diagnosis I understand that it is not within the scope of practice for acupuncturists to offer Western medical (biomedical) diagnosis, and that it is my responsibility to seek such diagnosis elsewhere if I have not already done so. I have / have not (circle one) been examined by a licensed physician or other licensed health care provider with regard to my illness or injury. If yes, I have informed the practitioner of the diagnosis. I do / do not (circle one) have a pacemaker or bleeding disorder. Patient (or Guardian) Signature Witness Date Date

9 300 N. Willson Ave, Suite 3002 Bozeman, MT (406) BEFORE YOUR FIRST APPOINTMENT The following are guidelines for patients to follow to get the most out of their acupuncture sessions. If you have any questions, please do not hesitate to contact your practitioner for more information: 1) Avoid caffeine, alcohol and excessive amounts of sugar and exercise the day of your appointment. Please refrain from wearing perfumes, colognes, or strong odors. Some patients may have chemical sensitivities. 2) Drink plenty of water the day before your appointment and try to come well-rested. 3) Please refrain from brushing your tongue the day before your treatment. The tongue coating serves as a diagnostic tool in Chinese medicine. 4) Eat a meal at least 1-2 hours before your acupuncture session. Side-effects such as needle sickness can be avoided by coming to your treatment with food in your stomach. Patients who have not eaten within hours of their session will be offered a snack (if available) or an alternate appointment time. 5) Please refrain from using your cellphone during your treatment sessions unless you have an emergency. This is a time for you to relax and tap into your body s healing abilities. Extraneous distractions and loud conversations should be avoided. 6) Arrive wearing loose comfortable clothing - skinny jeans, tight shirts, etc. are not ideal. 7) Please have your paperwork completely filled out before your session time begins, otherwise arrive 20 minutes early to fill it out in the office. If you arrive to your appointment at the scheduled time and have not filled out the paperwork, the treatment session will be cut short to accommodate for this. 8) If you are taking prescription or over-the-counter medications, please bring a list including the dosages you take. 9) Relax :) It s natural for many people to feel nervous about needles. My goal is to make the experience as comfortable as possible. If you have any questions or concerns please do not hesitate to ask questions!

Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation

Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation Island Acupuncture & Massage Therapy Patient General Information GENERAL PATIENT INFORMATION Last Name First Name Home Phone Cell Phone Work Phone Email Address (street) (city) (state) (zip) Date of Birth