HEALTH HISTORY Below you will find a number of questions related to your health history. While not all of the questions may seem directly related to your main complaint or reason for seeking care, your answers to these questions will inform your treatment throughout the course of your care at Keahi Health Acupuncture & Herbal Clinic. Therefore, we ask you to be as thorough and thoughtful as possible as you consider the questions below. GENERAL INFORMATION Name: Age: Today s Best number to reach you: If we are unable to reach you, do we have permission to leave a message on your voicemail or with the person who will answer the phone? Yes No Email: Appt Reminders? Yes No Mailing List? Yes No Emergency contact: Phone number: Relationship: Occupation: How many hours/week do you work? Marital Status: Single Married Divorced Separated Domestic Partnership Widow Living situation: Alone With partner/spouse With roommates With children With pets Have you had acupuncture treatment before? Yes No How did you hear about us? Insurance Online Referral Community Event What are your current expectations in seeking treatment? HEALTH CONCERNS Primary Health Concern: What caused the condition (if known): Is it getting worse? Yes No Is it aggravated by: Standing Sitting Driving Stress Does it bother your: Sleep Work Past treatments for this concern: Secondary Health Concern: Name of Your Primary Care Physician: Phone: Seen for what condition? Date of Last Visit: Other Medical Care Provider: Phone: I hereby authorize Keahi Health to contact my primary care physician, as needed: Signature Date
DIAGNOSTICS Which diagnostic studies have you had in the past year? Electrocardiogram (EKG) Electroencephalogram (EEG) X-Ray Bone Density Scan (DEXA) Mammogram MRI CBC Have you been diagnosed with a particular condition? MUSCULOSKELETAL/PAIN Please circle any areas of pain: Please list the area of pain and circle level of pain severity (1= very little pain, 10=worst pain imaginable) 1. Area: 1 2 3 4 5 6 7 8 9 10 2. Area: 1 2 3 4 5 6 7 8 9 10 3. Area: 1 2 3 4 5 6 7 8 9 10 Please circle all that apply: Sore Dull Achy Throbbing Pinching Pressure Stabbing Sharp Tingling Numb Electrical Tight DO YOU HAVE ANY OF THE FOLLOWING? Please circle any that you have currently and underline those that you ve Generalized muscle pain or stiffness Swollen, painful, stiff joints Bone pain Tremors, twitches Numbness or tingling Loss of strength Hernia Seizure Disorder Bleeding Disorder Bruise Easily Pacemaker Prosthesis Breast Implants Body Jewelry Implanted Electronic Device CURRENT MEDICATIONS Please circle any that you take: Laxatives Thyroid medication Pain relievers Coumadin Cortisone Antacids Hormones Sleep Aids Tranquilizers Antidepressants Anti-anxiety Oral Contraceptives Blood Pressure Cholesterol medication If you take or use the following, please list (use back of page, if necessary): Prescription Medications: 1. 2. 3. 4. 5. 2
Vitamins/Supplements/Herbals/Homeopathics: 1. 2. 3. 4. 5. HOSPITALIZATION, SURGERIES, & ACCIDENTS Have you had any of the following removed? List the date. Also list any surgeries and their dates. Tonsils: Cysts/Tumors: Appendix: Uterus/Ovaries: Gallbladder: Surgeries: Surgeries: SYMPTOM SURVEY Please circle any that you have currently and underline those that you ve GENERAL SYMPTOMS Nervousness, irritability, anxiety Mental tension Moodiness, depression, melancholy Tired, weak, lack of energy Sleeplessness, sleep too much Frequent colds or other illness Height: Current Weight: Headaches Don't sweat enough Sweat too much Night sweats Dizziness, convulsions, fainting, seizures Loss or gain of weight Weight 1 Year Ago: Max Weight: When: GASTROINTESTINAL Please circle any that you have currently and underline those that you ve Loss of appetite, excessive appetite Gagging, difficulty swallowing Nausea, vomiting Bad breath, taste in mouth Jaw Problems, grinding teeth Food cravings - i.e. sweet, salty, other Difficulty digesting fats Heartburn, indigestion or distress Heaviness or fatigue after eating Gas, belching, bloating Stomach or abdomen pain Symptoms relieved/worsened after eating Sensitivity/avoid certain foods Headache, dizziness, irritability if meals are skipped Diarrhea or loose stools Constipation Light colored or greasy stools Dark stools, blood in stools Undigested food in stools Feeling of incomplete evacuation Foul odor of stool or gas Hemorrhoids, anal fissure 3
URINARY Please circle any that you have currently and underline those that you ve experienced in the past: Difficulty urinating Urinate frequently at night Bed-wetting Incomplete urination or dribbling Urgency Pain when urinating Strong odor Blood in Urine Bladder infections Kidney infections Kidney stones EYE, EAR, NOSE, AND THROAT Please circle any that you have currently and underline those that you ve Near-sightedness, far-sightedness Blurred, failing vision, night blindness Dryness, burning, itching Eyes water excessively Sensitivity to light, floaters Bloodshot, puffy eyes Earaches Noises, ringing in ears Ear discharge, excessive wax Loss of hearing Difficulty breathing Shortness of breath on exertion Spitting up mucus or blood Chest pain Hay fever, sinusitis, runny nose Dry mouth or nose, dry or chapped lips Nosebleeds, bleeding gums Sore throats, tonsillitis Clear throat a lot Sore, red, cracked tongue Cold sores, herpes Loss of smell or taste Hoarseness CARDIOVASCULAR Please circle any that you have currently and underline those that you ve Irregular or fast heart beat Pacemaker Chest tightness Discomfort at high altitudes Dizziness or weakness on standing Swollen feet, ankles or legs Cold hands or feet Hands or feet turn blue Blue fingernails Leg pains when walking Varicose veins Tendency to anemia High blood pressure Low blood pressure SKIN AND HAIR Please circle any that you have currently and underline those that you ve Acne, pimples Brown spots, browning of skin Skin rashes, hives Moles, warts, skin tags Skin ulcers or sores Sunburn easily Flush easily Cuts heal slowly, scar badly Hair loss, thinning Dryness, roughness, scaling Dry, course hair, split ends Athlete's Foot, toe fungus Bruise easily 4
FEMALE - SPECIFIC 1st Day of Last Period: Typical # of bleeding days: Typical Length of cycle: Date of last pap smear: Was it normal? Number of pregnancies: Number of live births: Number of miscarriages: Number of abortions: Are you pregnant? Yes No How many weeks? Bleeding between periods Depressed, tense, irritability w/ periods Painful or swollen breasts Discharge from breasts Lumps in breasts MALE - SPECIFIC Difficult or unusual urination Discomfort or pain in genital area Diminished or excessive sexual desires Difficulty in maintaining an erection Premature ejaculation Irregular cycles Pain during intercourse Diminished or excessive sexual desire Difficulty having orgasm Painful menses, clotting Excessive flow Vaginal discharge/dryness Pain, discomfort, itching in genital area Use birth control Difficulty conceiving Menopausal symptoms STDs Do you or have you ever used birth control/iud? Yes No Prostate problems Hernias STDs Date of last prostate exam: MISCELLANEOUS Traveled outside the USA within the last two years to: Have you ever been diagnosed or exposed to the following: HIV Diagnosis & Treatment Dates: Hepatitis Diagnosis & Treatment Dates: Tuberculosis Diagnosis & Treatment Dates: Have you ever been exposed in significant or long-term doses to: Chemicals Toxins Radiation HABITS/LIFESTYLE How do you rate your stress level on a scale of 1-10? 0 lowest, 10 highest: Do you consume: Cigarettes or tobacco Coffee/tea/soda Sugar Processed/Fast foods Alcohol Marijuana/other drugs Water Exercise Packs a day: Cups a day: Times a day: Times a day: Drinks per week: Times per week: Glasses per day: What and how often? 5
TYPICAL FOOD INTAKE Breakfast: Lunch: Dinner: Snacks: Drinks: Do you strongly desire any particular foods? Do you strongly dislike any particular foods? Are there any foods that aggravate any of your symptoms or make you feel bad? ALLERGIES Are you hypersensitive or allergic to any of the following? Please list. Medications Foods Plants Animals Pollens Environmental Chemicals Latex MSG Other FAMILY HISTORY check all that apply Conditions Self Mother Father Grandparents Siblings Children Heart disease Cancer Diabetes Digestive Respiratory Urinary Thyroid Mental Health Allergies Arthritis Anemia Stroke Please check here if you are adopted or otherwise unaware of your family's medical history Patient Name (Please Print) Patient Signature (or Guardian) Date 6