Health History Questionnaire
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- Dorthy Paul
- 5 years ago
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1 Health History Questionnaire Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Mobile Phone: Date of Birth: Place of Birth: Height: Weight: Relationship Status: Employer: Single Married Separated Divorced Living w/partner Other : Occupation: Physician Physician s Phone Number: Emergency Contact Name: Emergency Contact Phone Number: Referred By: Have you previously been treated for acupuncture or Oriental Medicine? Yes No / / What is your main concern today? When did this problem/condition begin? (Please be specific) What do you think is the cause? Is the cause still present? What treatments have you already tried? What were the results? Have you received a diagnosis for this problem/condition? If so, what is the diagnosis? To what extent does the problem/condition interfere with your daily activities? (work, sleep, eating, etc.)
2 How severe is your problem/condition right now? (Please mark the below scale) No Problem Moderate Severe How severe is your problem/condition right now? (Please mark the below scale) No Problem Moderate Severe Past Medical History (please indicate by dates) Cancer High Blood Pressure Rheumatic Fever Venereal Disease Diabetes Heart Disease Seizures Allergies Hepatitis Stroke Thyroid Disease Pacemaker Other: Surgeries (type and date): Significant Trauma (auto accident, falls, etc.) Birth History (prolonged labor, forceps delivery, caesarian section, other): Allergies (drugs, food, animals): Family Medical History High Blood Pressure Alcoholism Cancer Allergies Heart Disease Seizures Arteriosclerosis Asthma Stroke Diabetes Occupational stress (chemical, physical, psychological, etc.): Do you exercise regularly? Y or N Please describe: Comments (please list any other problems you would like to discuss):
3 Indicate Painful or Distressed Areas What are Your Treatment Goals? Temporary relief of symptoms/pain control Eliminate root or cause of the problem (if possible) Lessen/eliminate habits which caused the condition or made it worse Maintenance care (periodic balancing/tune-up to keep in good health) Please check any boxes of symptoms you have had in the past month. General Chills Fever Sweat easily Night sweats Localized weakness Bleed or bruise easily Peculiar tastes or smells Strong thirst (hot/cold) Thirst, no desire to drink Fatigue Sudden energy drop Time of day: Edema Where: Poor sleeping Tremors Poor balance Cravings Change in appetite Poor appetite Weight change Gain/Loss Skin and Hair Rashes Itching Change in hair or skin Ulcerations Eczema Oozing skin lesion Hives Pimples Recent moles Loss of hair Dandruff Other hair or skin problems: Head, Eyes, Ears, Nose, and Throat Dizziness Migraines Headaches When: Where: Facial Pain Glasses Poor vision Night blindness Blur vision Color blindness Blind field Spots in front of eyes Eye pain Eye strain Cataracts Eye dryness Excessive tearing Discharge from eyes Poor hearing Ringing in ears Earaches Discharge from ear Nose bleeds Sinus congestion Nasal drainage Grinding teeth Teeth problems Jaw clicks Concussions Recurrent sore throat Hoarseness Sores on lips/tongue Other head/neck problems: Cardiovascular High blood pressure Low blood pressure Chest discomfort/pain Heart palpitations Cold hands or feet Swelling of hands Swelling of feet Blood clots Fainting Difficulty in breathing Other heart/blood vessel problems: Respiratory Cough Asthma/wheezing Difficulty in breathing while lying down Phlegm Color? Coughing blood Pneumonia Bronchitis Other lung problems: Gastrointestinal Bad breath Nausea Vomiting Heartburn Belching Indigestion Diarrhea Constipation Chronic laxative use Blood in stools Black stools Abdominal pain/cramps
4 Gas Rectal pain Hemorrhoids Other stomach or intestinal problems: Genito-Urinary Pain on urination Urgency to urinate Frequent urination Blood in urine Decrease in flow Dribbling Kidney stones Impotency Change of sexual drive Sores on genitals Do you wake to urinate? Yes No How often? Urine color? Other genital or urinary system problems? Pregnancy and Gynecology # of pregnancies: # of births: # of premature births: # of miscarriages # of abortions Age at first menses: Length of full cycle: Length of menses: Last menses start date: Last pap smear: Heavy periods Light periods Painful periods Irregular periods Changes in body/psyche prior to menstruation Clots Vaginal discharge Menopause Age: Year: Postcoital bleeding Vaginal sores Breast lumps Nipple discharge Practice birth control? Yes No What type? How long? Musculoskeletal Neck pain Shoulder pain Back pain Elbow pain Hand/wrist pain Hip pain Knee pain Foot / ankle / heel pain Muscle pain Muscle weakness Other pain? Neuropsychological Seizures Areas of numbness Weakness Sleep disorder Concussion Violence potential Vertigo Lack of coordination Bad temper Depression Easily stressed Loss of balance Poor memory Anxiety Substance abuse Have you ever been treated for emotional problems? Yes No Habits Please indicate below: None, Minimal, Moderate, Excessive None Minimal Moderate Excessive Add comments/quantities when appropriate Alcohol Coffee Tea Tobacco Drugs Water intake Vitamins Sugar intake Food intake Appetite Sleep
5 Habits (con t) Other: None Minimal Moderate Excessive Add comments/quantities when appropriate Exercise Energy level Stress level Dental Problems Diet Please give a general description of the food you consume during a typical day: Morning: Afternoon: Evening: Between meals: Before bed: Medicine Please list all medications you are taking, and for what condition. Please include prescriptions, vitamins, over-the-counter, etc.) Medicine Condition Consent for Treatment I, the undersigned, understand acupuncture may involve the use of needles, electric stimulation TDP heat therapy, cupping, gua sha, etc. The risks, although limited, include puncturing organs in the abdomen and chest cavities, and bruising. Acupuncture and/or massage therapy can affect people on all levels: physical, emotional, mental, and spiritual because it works with the whole body to create balance. The duration and course of treatment varies from person to person depending on their specific condition and overall constitution. I fully understand that there is no stated or implied guarantee of success or effectiveness after a specific treatment or course of treatments. Signature Date
6 For Patient Review Regarding Diagnostic Exam Please Sign one of the two options listed below. Option 1: I have received a diagnostic exam by a physician or chiropractors within the last six months regarding the condition for which I am seeking treatment. Patient Signature Date Option 2: I have NOT received a diagnostic exam by a physician or chiropractor within the last six months regarding the condition for which I am seeking treatment. Ohio law requires that a Licensed Acupuncturist recommend that ou receive a diagnostic examination from a physician or chiropractor regarding the condition for which you are seeking tratment. I understand this recommendation. Patient Signature Date Licensed Acupuncturist Signature Date CC: Patient file Provided to patient
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Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
Rockwood Natural Medicine Clinic
Rockwood Natural Medicine Clinic 9755 N. 90 th St., Suite A-210 Scottsdale, Arizona 85258 480-767-7119 Date: Name: Age: Sex: M F Are you: Married Separated Divorced Widowed Single How did you hear about
What do you believe is causing your most important health concern?
Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to
Chinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone: Emergency contact name & phone number: Relationship Status:
Chinese Medicine Adult Intake Form Name (Last, First): Date of Birth: Occupation: Hours per week: Home address: Phone: Email: Preferred contact method (circle one): Phone / Email Emergency contact name
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
Balanced Healing Acupuncture, LLC
Balanced Healing Acupuncture, LLC Intake Form NAME: Last First: GENDER: Date of Birth / / Age Email Address Address City State Zip Code Preferred Phone Number Cell Home Work Preferred Method of Communication:
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician: