Wisdom Ways Acupuncture

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Wisdom Ways Acupuncture 363 W. Drake Suite 1, Fort Collins, CO 80526 Phone (970) 227-3077 Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally, and emotionally. Please complete this questionnaire as thoroughly as possible. Print all information and indicate areas of confusion with a question mark. Thank you. 1. When and where did you last receive health care For what reason? 2. Has your case been referred to an attorney? Y N 3. Please identify the health concerns that have brought you to the Wisdom Ways Acupuncture Clinic, in order of importance below: Condition Past Treatment a. b. c. 4. If applicable, please list any foods, drugs, or medications to which you are allergic (please include reaction): 1

5. Please list any medications (prescribed and over-the-counter), vitamins, and supplements you are currently taking: 6. Do you have any reason to believe you may be pregnant? Y N If so, how far along are you? 7. Do you have any infectious diseases? Y N If yes, please identify: 8. Family History: Father Mother Brothers Sisters Spouse Children Check those applicable: Age (if living) Health (G=Good, P=Poor) Cancer Diabetes Heart Disease High Blood Pressure Stroke Mental Illness Asthma/Hay fever/hives Kidney Disease Age (at death) Cause of Death 9. Height: Weight: Currently: Past Maximum: When? 10. Blood Pressure: What is your most recent blood pressure reading? / When was this reading taken? 11. Childhood Illness (please circle any that you have had): Scarlet Fever Diphtheria Rheumatic Fever Mumps Measles German Measles Chicken Pox 12. Hospitalizations and Surgeries: Reason When Reason When _ 2

13. X-Rays/CAT Scans/MRI s/nmr s/special Studies: Reason When Reason When _ 14. Emotional (please circle any that you experience now and underline any that you have experienced in the past): Mood Swings Nervousness/Anxiety Mental Tension Depression Disturbing Dreams 15. Energy and Immunity (please circle any that you experience now and underline any that you have experienced in the past): Fatigue Slow Wound Healing Chronic Infections Chronic Fatigue Syndrome 16. Head, Eye, Ear, Nose, and Throat (please circle any that you experience now and underline any that you have experienced in the past): Impaired Vision Eye Pain/Strain Glaucoma Tearing/Dryness Chronic Red Eyes Impaired Hearing Ear Ringing Earaches Headaches/Migraines Sinus Problems Nose Bleeds Frequent Sore Throats Teeth Grinding TMJ/Jaw Problems Hay Fever 17. Respiratory (please circle any that you experience now and underline any that you have experienced in the past): Pneumonia Frequent Common Colds Difficulty Breathing Emphysema Persistent Cough Pleurisy Asthma Tuberculosis Shortness of Breath Other Respiratory Problems: 18. Cardiovascular (please circle any that you experience now and underline any that you have experienced in the past): Heart Disease Chest Pain High Blood Pressure Palpitations/Fluttering Stroke Heart Murmurs Rheumatic Fever Varicose Veins 19. Gastrointestinal (please circle any that you experience now and underline any that you have experienced in the past): Ulcers Changes in Appetite Blood in stool Abdominal Pain Gas/Belching Heartburn Bloating Constipation Diarrhea Nausea/Vomiting Gall Bladder Disease Hemorrhoids Can t tolerate raw foods 20. Genito-Urinary Tract (please circle any that you experience now and underline any that you have experienced in the past): Kidney Disease Painful Urination Frequent UTI Frequent Urination Heavy Flow Kidney Stones Impaired Urination Blood in Urine Frequent Urination at Night 21. Female Reproductive/Breasts (please circle any that you experience now and underline any that you have experienced in the past): Irregular Cycles Heavy Flow Light Flow Clots Dark brownish menses Very pale menses Mucousy menses 3

Painful Periods Bleeding Between Cycles Premenstrual Problems Abnormal Vaginal Discharge Vaginal itching Menopausal Symptoms Difficulty Conceiving Breast Lumps/Tenderness Nipple Discharge 22. Menstrual/Birthing History: 1. Age of First Menses: 2. # of Days Bleeding: 3. Length of Entire Cycle (i.o.w day 1 to day 1): 4. Birth Control Type: 5. # of Pregnancies: 6. # of Miscarriages: 7. # of Abortions: 8. # of Live Births: 23. Musculoskeletal (please circle any that you experience now and underline any that you have experienced in the past): Neck/Shoulder Pain Muscle Spasms/Cramps Arm Pain Upper Back Pain Mid Back Pain Low Back Pain Leg Pain Joint Pain (if so, where?): 24. Neurologic (please circle any that you experience now and underline any that you have experienced in the past): Vertigo/Dizziness Paralysis Numbness/Tingling Loss of Balance Seizures/Epilepsy 25. Endocrine (please circle any that you experience now and underline any that you have experienced in the past): Hypothyroid Hyperthyroid Hypoglycemia Diabetes Mellitus 26. Temperature (not what thermometer says, but how you FEEL) Normal Tend to Warm Extreme HEAT Tend to Cold Extreme COLD Can t tolerate either extreme Extreme Cold Hands/Feet (when rest of body normal temp) If extreme, what other symptoms will you get if you get overheated or overly cold: Is there a time of day/night when you regularly feel a change in temperature? 27. Thirst: normal never thirsty always thirsty thirsty with no desire to drink Prefer variable temperature liquids depending on weather Always prefer ice cold drinks Always prefer hot drinks 28. Fluid metabolism Swelling (location/s): changes with cycle Sweat: normal feels excessive not enough not at all excessive odor greasy yellow At these times or under these conditions: 29. Other (please circle any that you experience now and underline any that you have experienced in the past): Anemia Cancer Rashes Eczema/Hives 4

29. Lifestyle: a. Do you typically eat at least three meals per day? Y N If no, how many? Do you consider them balanced? Y N Do you know what a balanced meal is? Y N Are you aware of changes in your symptoms/energy/moods based on what you eat? Y N Do you typically crave certain types of food? (i.e. salty/crunchy, sweet, fatty) Y N If yes, what type? Do you enjoy cooking and/or eating healthy foods? Y N Do you think you have, or have ever had, an eating disorder? Y N If yes, please explain: Are there foods for which you have sensitivities: If so, please list and include the symptoms you ll get when you eat them: b. Exercise activities: How many times per week? times Do you enjoy exercise? Y N c. Spiritual practice: d. How many hours per night do you sleep? Do you wake rested? Y N Is it hard to fall asleep? Y N If yes, once you fall asleep, do you generally stay asleep? Y N Is it hard to stay asleep? Y N If so, is there a typical time in which you usually wake? pm/am Do you often feel tired throughout the day? Y N If so, is there a typical time in which this happens? pm/am If so, is it associated with pre or post-eating? Y, pre Y, post N e. Level of education completed: High School Bachelors Masters Doctorate Other f. Occupation: Employer: Hours/Week: Do you enjoy work? Y/N Why/Why not? g. Nicotine/Alcohol/Caffeine Use: h. Have you experienced any major traumas? Y N Explain: i. How many glasses of non-caffeinated, non-carbonated liquids do you drink per day? How many sodas? j. Television habits: Reading habits: k. Do you have a satisfying network of support and friends? Y N If not, do you see this as a problem? Y N l. Interests and hobbies: 5

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