Health History New England Community Acupuncture

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Transcription:

Health History New England Community Acupuncture Name: Contact - Cell: Street: Home: City: Work: State: Zip: Email: DOB: Height: Occupation: Age: Weight: Physician: Emergency Contact - Name & Phone Number: How did you hear about NECA: Main Complaint(s): 1-2- 3- How long ago did this begin: Have you consulted a physician: Have you been given a diagnosis, if so, what: What forms of treatment have you tried: Have you tried acupuncture or Chinese herbal medicine before: Past Medical History - Please circle all applicable to you: Cancer Diabetes Hepatitis A, B, C High Blood Pressure Heart Disease HIV Seizures Auto Immune Thyroid Disease Pace Maker Depression IBS Hysterectomy Kidney Disease Prostate Issues Significant Trauma, auto accidents, injuries: Sugeries and Dates: Other Significant Illness(es): Woburn 323 New Boston St. Suite 2 Woburn, MA 01801 781.933.8088 North Andover 733 Turnpike St. (Rt. 114) Jasmine Plaza North Andover, MA 01845 978.258.0427

Medications:(include prescription, OTC, vitamins, herbs etc) Do you currently take a multivitamin or antioxidant? Yes No Average Diet Morning Afternoon Evening Daily Health - Habits Do you smoke? Yes No - If yes, how much? How much soda do you drink in a week? Do you drink Diet beverages? Is more than 25% of your diet frozen, canned, boxed or processed foods? Yes No How much water do you drink in a day? How much coffee do you drink in a day? How much alcohol do you drink in a week? Describe how you feel about your appetite - Too Good Just Right Not Good Enough Average number of hours of sleep per night? Please indicate areas of pain 2

General Fevers Strange Tastes or Smells Poor Sleep Sweat Easily Cravings Fatigue Night Sweats Change in Appetite Sudden Energy Drop Running Warm Weight Loss Cold Hands Feet Running Cold Weight Gain Strong Thirst Skin and Hair Rashes Ulcerations Hives Itching Oozing Ulcers Recent Moles Dandruff Eczema Discoloration Dry Skin Psoriasis Infection Brittle Nails Hair Loss Other: Head Dizziness Poor Vision Migraines Vertigo Eye Tenderness Tension Headaches Ringing in Ears Eye Twitching Sinus Congestion Ear Blockage Eye Tearing Sore Throats Facial Pain Dry Eyes Post Nasal Drip Teeth Grinding Spots/Floaters in Vision Nose Bleeds TMJ Poor Night vision Cloudy Fogginess Cankersores - Mouth Ulcer Cataracts Concussion Cardiovascular Chest Pain/Tightness Fainting Blood Clots Irregular Heartbeat Cold Hands or Feet Peripheral Artery Disease High / Low Blood Pressure Swelling in Limbs Varicose Veins Respiratory Cough Asthma Production of Phlegm Coughing Blood Difficulty Breathing Pneumonia Bronchitis Wheezing Short of Breath Gastrointestinal Nausea Gas Abdominal Pain - Cramps Vomiting Belching Rectal Pain - Burning Indigestion Diarrhea Hemorrhoids Acid Reflux Constipation Blood in Stool Bloating Sluggish Bowel Undigested Food in Stool Other: 3

Urinary Frequent Urination Pain Upon Urination Inability to Empty Bladder Urgency to Urinate Blood in Urine Weak Stream Incontinence Frequent UTIs Kidney Stones Dark Color to Urine Strong Odor to Urine Frequent Night Urination Male Health Impotence Low Sperm Count Low Libido Premature Ejaculation Low Motility STDs Enlarged Prostate Testicular Pain Other: Female Health Are you or is it possible Age of first period: Duration of Period: that youre pregnant: Days between Day 1 of period: # of Live Births: Using Birth Control: # of Miscarriages: Heavy Period Uterine Fibroids Vaginal Discharge Light/Scanty Period Ovarian Cysts Frequent Yeast Infections Painful Period Endomitriosis STDs Breast Tenderness Clots in Blood Flow Infertility Issues Period begins with spotting PMS Spotting During Ovulation Musculoskeletal Neck Pain Hand / Wrist Pain Overall Muscle Achiness Shoulder Pain Foot / Ankle Pain Muscle Weakness Back Pain Hip Pain Herniated Discs Sciatica Knee Pain Other: Neurological Seizures Dizziness / Vertigo Areas of Numbness Stroke Loss of Balance Tremors Concussion Confusion Neuropathy - Nerve Pain Other: Emotions Depression Insomnia - mind racing Panic Attacks Anxiety Fearful Cloudy Foggy Mind Anger Phobias Other: Are you currently being treated for emotional or psychological issues: Have you ever considered or attempted suicide? 4

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Dear Valued Patients: NECA treats a large patient base and sometimes needs to turn patients away because our schedule is full. In order for us to provide affordable care we are largely dependent upon you keeping your scheduled appointment. We ask that you please be sensitive to our mission, the needs of our clinic, and the time of our professional staff. All appointments that are cancelled with less than 24 hours notice, or are missed altogether without letting our front desk know, will be charged a $10.00 fee payable at the next visit. We do recognize that real emergencies happen, and would be happy to consider these on an individual basis. Thanks for understanding and in doing so, helping us to keep our fees as low as possible. We appreciate your business. Thank you. The NECA Family! Signature

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