FAMILY MEDICAL HISTORY:

NAME DATE PHONE(home) (work) cell E-mail (for office use only) ADDRESS CITY/STATE ZIP AGE HEIGHT WEIGHT SEX MARITAL STATUS BIRTH DATE OCCUPATION EMPLOYERS NAME EMPLOYERS ADDRESS PERSONAL PHYSICIAN DATE OF LAST PHYSICAL EXAMINATION EMERGENCY CONTACT RELATIONSHIP PHONE REFERRED BY Acupuncture has been explained to me as a treatment consisting of inserting needles through the skin at specific points on the surface of the body,(small amount of electrical current may be applied to the needles). The purpose of acupuncture has been explained as the alleviation or cure of symptoms or disorders. Massage, acupressure, acupuncture, reflexology, preventative or corrective exercise and nutritional or herbal counseling are considered experimental procedures and are not considered a substitute for Western Medicine. Therapies and advice offered shall not be construed by the client to be a diagnosis of treatment of any disease or injury. It is recommended that you CONSULT YOUR PHYSICIAN for any serious conditions and get at least two medical opinions. It is your right and responsibility for your own body. I understand that complications can result from acupuncture treatment. Among these possible complications are areas of anesthesia, fainting, weakness, nausea, hematoma, infection, pain and discomfort, pneumothorax and aggravation to present symptoms. Client further understands and agrees to hold harmless, to indemnify and protect against court action the therapist, management and owners of this clinic, in the unlikely event of accidental injury on these premises. Signed Date FAMILY MEDICAL HISTORY: parents and grandparents health Cancer Diabetes High or Low Blood Pressure Heart Disease TB/Emphysema Allergies/Sinus problems Kidney Disease Epilepsy/Seizures Asthma Liver Disease Stomach Ulcers Mental Disorders Eye Disease Arthritis Alcoholism Spinal Problems Osteoarthritis Drug Addiction

MAJOR COMPLAINT, INJURY OR ILLNESS Describe when it began and what caused it or how it started: Have you ever had this condition or similar condition before? Yes No Have you ever received treatment? Yes No If yes, when? By whom? What was the diagnosis? Has the treatment gotten: Better Worse Is about the same What makes it Better? What makes it worse? PERSONAL MEDICAL HISTORY Major Surgeries Illnesses-Disease Accident (please date is possible) Please List all Medications Vitamins Herbs

CONTAGIOUS DISEASES (Check if you have ever had or currently have one of the following): Hepatitis AIDS HIV + Venereal Disease Herpes Other ALLERGIES drugs foods animals seasonal LIFESTYLE HABITS: Cigarettes Soft Drinks Salt Coffee Alcohol Recreational Drugs Black Tea Sugar Stress Scale 1 2 3 4 5 6 7 8 9 10 EXERCISE: Never Little Moderate Heavy Type of exercise? EMOTIONS: Happy Worry Easily Irritable Difficulty making decisions Angry Sad Cry easily Hurry to do things Fearful Anxiety Over think or worry History of Depression? DIET (please mark with x all foods eaten and cross off foods you avoid) Beef Eggs Cheese Grains Tofu Pork Bread Margarine Fried Food Yogurt Poultry Milk Ice Cream Sweet Health Bars Fish Butter Vegetables Salads Hot Spicy Other Cravings Do you eat three meals per day? Yes No Do you eat at regular hours? Yes No what times do you eat?

APPETITE: Up and Down Poor Constant hunger Loss of taste WEIGHT: Underweight Overweight Recent gain Recent loss ENERGY: Up and Down Low Excess Tired in afternoon Wake up tired Low after eating GENERAL SYMPTOMS BODY TEMPERATURE: Warm natured Cold natured Cold hands and feet Flushed Face Warm palms Warm soles Feel warm late afternoon or night PERSPIRATION: Very Little Easily Night sweats Profuse Palms Bad smell Without exertion Feet DIGESTION AND BOWELS Indigestion Nervous Stomach Bloating Heartburn Nausea/Vomiting Full feel or distention Belch or burp Stomach noises Abdominal pain or cramps Gas Bad breath Difficulties with fatty or oily food Bitter taste in mouth Gallstones Weight Problems Ulcers BOWELS: How frequent do you have a bowel movement? times daily Loose stool Blood in stool Undigested food in stool Diarrhea Small amount of stool Stool with very bad smell Formed stool Black stool Constipation: for how long? Hard stool Mucous in stool Anus Itch Colon problems Burning Anus Hemorrhoids Intestinal worms/parasites Pain or cramps Use of laxatives

URINATION: Frequent Burning Bladder infections HISTORY OF: Nighttime Blood Incontinence Kidney Stones Profuse Pus Strong Smell Kidney infections Cloudy Scanty Painful Not normal color Urgency Genital Pain Prostrate Problems Pain or burning Dribble urine during urination THIRST: Less than normal Prefer cold drinks Prefer hot/warm drinks Excessive thirst SLEEP: Difficulty falling asleep Lots of dreams Tired upon rising Awake easily Nightmares Sleep too much Difficulty going back to sleep Restless How many hours of sleep do you prefer? How many do you actually get? HEADACHES - DIZZINESS: Headaches Vertigo Bend down/up dizziness Dizziness Motion sickness Poor balance Faint easily Migraines Poor memory SKIN: Dry Hives Clammy Oily Bruise easily Body odor Rashes Cuts heal slowly Itching Yellow skin Eczema Boils HAIR: Dry Dandruff Early grey Oily Falling out

EYES: Wear glasses/contacts Cataracts Red Spots or lines in vision Glaucoma Dry Poor night vision Pain Itch Sensitive to light EARS: Poor hearing Ringing (high pitched) Discharges Ear ache Ringing (low pitched) NOSE: Current stuffy nose Hay fever/allergies Sneeze a lot Mucous Bleeding Loss of smell Sinusitis Rhinitis Date or season of last cold or flu MOUTH AND THROAT: Dry Gum problems TMJ/Grind Hoarseness Sores in mouth/on tongue Thyroid problem Swollen glands Feel lump in throat Teeth problems RESPIRATORY: Shortness of breath Difficulty inhaling Cough with blood Chest pain Difficulty exhaling Dry cough Asthma Difficulty breathing when lying down Cough with phlegm Bronchitis Tightness in chest Sigh a lot CARDIOVASCULAR - CIRCULATION: Diagnosed heart problems Low blood pressure High blood pressure Murmur Slow heart beat Irregular heart beat Palpitations High cholesterol Varicose veins Bruise easily Numbness of extremities History of anemia

PAIN: Head Shoulder Arthritis Neck Elbow Damp weather Upper back Hands or wrist Nerve Mid back Hips Numbness Lower back Flank area Other Spine Knees Sciatica Foot or ankle Mark areas of pain

FOR FEMALES ONLY: Are you or might you be pregnant? Yes No Maybe If yes, what is the approximate date of conception? Do you have regular Pap Test? Yes No How regular? Do you do regular breast exams? Yes No How regular? GYNECOLOGICAL HISTORY AND OPERATIONS: Ovaries Breast Uterus Vagina Fallopian tubes Other What method of birth control do you now use? What method of birth control have you used in the past? PREGNANCIES: Total Number: Number of children: PREGNANCY OR CHILDBIRTH COMPLICATIONS: MENSTRUAL CYCLE: Age started: Age stopped: How many days between periods? How many days of flow? Describe flow: Does it begin as bright red or as a darker brownish red? What is the coloring at the end? PMS SYMPTOMS Irregular Clotting Backache Water retention Dark color flow Sigh a lot Light color flow Scanty flow Lump in throat feeling Abdominal bloating Heavy flow Constipation and/or diarrhea Painful or tender breast Painful Spotting in between cycle Breast lumps Tightness in chest Hormonal problems Emotional changes VAGINAL DISCHARGE: White Yellow Thick Bad odor Clear

OVULATION SYMPTOMS: Are you aware of when ovulation occurs? Yes No If so, please describe the symptoms or sensations Menopausal problems? Yes No Please describe: FOR OFFICE USE ONLY: Patient name: Date: Tongue: Pulse Rate: Left: HT LV KD Yin Right: LU SP KD Yang Diagnosis: Treatment Plan: POINTS USED: Future Treatment: Lifestyle and Herbal recommendations: