Have you had all childhood diseases i.e.? chickenpox. Y N. Have you ever suffered from an infectious illness? i.e. glandular fever.
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1 Acupuncture case history card Name: Date: Address: Ph No: (H) (W) (M) Fax: D.O.B Sex: M F Marital Status: Occupation: Dr: Suburb: Referred by: Health fund Medical history For the following questions, please tick the appropriate box. Have you had all childhood diseases i.e.? chickenpox. Y N Have you ever suffered from an infectious illness? i.e. glandular fever. Do you have or have you ever had a medical condition? i.e. asthma Have you ever had a motor vehicle accident? N Y Have you ever had any accidents/falls? Have you ever had a fracture/dislocation? Have you ever been hospitalised? Have you ever had surgery? Do you get pain during your sleep hours? Has your weight changed in the last year? N Y Have you got any significant scars? Are you taking any prescribed medication? N Y 1
2 Do you take minerals/vitamins? N Y Have you or do you consume any of the following? Tick those that apply. alcohol social drugs cigarettes tea coffee water Do you have any disorders of the following organs? Tick those that apply. eyes nose ears lungs heart liver stomach spleen pancreas small intestine colon reproductive organs bladder nerves muscle bones blood skin kidney Do you ever get dizzy? N Y Do you suffer from headaches/migraines? N Y practitioner notes Do you suffer from pain? N Y practitioner notes When was your last visit to the GP and what for? 2
3 Have you ever had any x-rays/scans? N y Has or does anyone in your family suffer from: diabetes cancer arthritis heart condition other General health questions: Digestive system: Diet: practitioner notes Do you get abnormally thirsty? regularly occasionally never Is your appetite? excessive good/normal poor Do you crave any of the following flavours? sweet sour bitter spicy salt regularly occasionally never Do you perfer food that is: warm cold no preference Do you ever get a abnormal taste in your mouth? N Y Do you ever suffer from: regularly occasionally never bloating belching nausea vomiting heart burn reflux flatulence 3
4 Sleep: How many hours on average do you get a night? Do you sleep well? Y N Do you wake rested? Y N Do you get tired during the day? Do you suffer from insomnia? Sweat: Do you sweat? normally profusely never Do you get night sweats? N Y What climate do you prefer? hot warm humid cold windy wet damp dry no preference Temperature: Do you have an aversion to any of the above climates? N Y Do you get cold hands or feet? N Y Do you get hot hands or feet? N Y Urination: How many times per day do you pass water? Is the colour: dark yellow yellow light yellow cloudy clear Is there an odour? _ Do you have to get up at night and urinate? N Y (what time/how often) Do you suffer from any of the following? please tick the boxes which apply to you. incontinence dribbling urgency to urinate pain/burning on urination difficulty to initiate urination 4
5 Stools: How often do you empty your bowels? Do suffer from constipation? Do you suffer from diarrhoea? Do you ever notice undigested food in you stools? Do you ever notice blood in your stools? Do you ever notice mucous in your stools? Do you have haemorrhoids? _ Emotions: Have you ever suffered from? tick the box if it applies. depression anger irritability grief sadness too much sympathy for others fear_ anxiety mental illness emotional trauma 5
6 Menstruation: FOR FEMALES ONLY Do you menstruate? Y N If your periods have finished - could you still please complete the questionnaire as your periods were. Do you get hot flushes? Are you or have you ever been on the contraceptive pill? Are you pregnant? PMT: Before your period starts do you ever suffer from the following? please tick. sore breasts stiff joints/muscles constipation fluid retention dizzyness palpations tingling/numbness in hands & feet depression anger irritable tearful lower abdominal pain lower back pain regularly occasionally never If you do suffer from any of the above - how many days before do you get symptoms? 6
7 Do you suffer from any of the following during your period? please tick appropriate box. sore breasts stiff joints/muscles constipation fluid retention dizzyness palpations tingling/numbness in hands & feet depression anger irritable tearful lower abdominal pain lower back pain regularly occasionally never If you do suffer from any of the above during your period, on what days? Have your periods always been the same? Y N How many days do you menstrate? How many days is your cycle? Is your flow? heavy medium light days heavy medium light days heavy medium light days What is the colour of the blood? brownish light red dark red bright red red Do you get clots? Vaginal discharge: What is the colour? Is there an odour? N Y 7
8 Chief complaint/location: Mechanism of injury: Type of pain: Duration: Time of pain am/pm: Pain scale: Better/worse /same: Aggravating factors: Relieving factors: Activities affected: Radiation: Associated Symptoms: CurrentRx: Previous episodes & Rx: Tongue Pulse Rx principle Rx 8
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