Ageless Acupuncture Patient Health History

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Transcription:

Ageless Acupuncture Patient Health History Name: Date: By what name would you like us to refer to you?: Street Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell Phone: How early/late may I call you? Email Address: May I send you information by email? Y N Date of Birth: Gender: M F Marital Status: S M D W SO Separated Emergency Contact: Relationship: Telephone: 1. Are you currently receiving health care? Y N 2. Do you have a pacemaker? Y N 3. Please identify the health concerns that have brought you to the clinic today: Condition Past Treatment/Impact on Quality of Life a. b. c. d. 4. Do you have any reason to believe you are pregnant? Y N 5. Height: Weight: Max Weight: When: 1

6. Childhood Illness (please circle any you have had): Scarlet Fever Diphtheria Rheumatic Fever Mumps Measles Chicken Pox 7. Immunizations (please circle any you have had): Polio Tetanus Measles/Mumps/Rubella Pertussis Diptheria Hepatitis B Other 8. Do you have any chronic infectious diseases? Y N If yes, please explain: 9. Are you currently suffering from any chronic illness? Y N If yes, please explain: 10. Severe Illnesses: 11. Please list all allergens, foods, drugs, and medications you are hypersensitive or allergic to and the type of reaction: 12. Please list all prescription medications (and their purposes) that you are currently taking: Medication Date started Reason for taking Any side effects 13. Please list all over-the-counter medications, vitamins, and supplements that you are currently taking: (Include antacids, cold/flu, sleep, allergy and pain medications) Supplement Date started Reason for taking Any side effects 14. Hospitalizations and surgeries: Reason When Reason When 2

15. X-Rays/CAT Scans/MRI s/special studies: Reason When Reason When Current Primary Care Physician: Date last seen: / / Reason: Clinic name: Phone: Address: Fax: City/State/Zip: Other Healthcare practitioners Type: (L.Ac., DC, LMT, ND, etc) Phone/Fax: Describe your ideal doctor or healthcare provider: Coping techniques for dealing with stress: 16. Family History: Mother Father Siblings Spouse Children Deceased (Y/N) Cause of death Age Health (G=good, P=Poor) Check any conditions that family members have had: Cancer Diabetes Heart Disease High Blood Pressure Stroke Mental Illness 3

Please CIRCLE current, UNDERLINE past experiences 17. Emotional Mood Swings Nervousness Mental Tension 18. Energy and Immunity Fatigue/Chronic Fatigue Syndrome Slow Wound Healing 19. Head, Eye, Ear, Nose, Throat Impaired Vision Eye Pain/Strain Glaucoma Glasses/Contacts Tearing/Dryness Impaired Hearing Ear Ringing Earaches Headaches Sinus Problems Nose Bleeds Teeth Grinding Frequent Sore Throats TMJ/Jaw Problems Hay Fever 20. Respiratory Pneumonia Frequent Common Colds Difficulty Breathing Emphysema Persistent Cough Pleurisy Asthma Tuberculosis Shortness of Breath Other: 21. Cardiovascular Heart Disease Chest Pain Swelling of ankles High Blood Pressure Palpitations Stroke Heart Murmurs Rheumatic Fever Varicose Veins 22. Gastrointestinal Ulcers Changes in Appetite Nausea/Vomiting Abdominal Pain Heartburn Belching Liver Disease Hepatitis B or C Hemorrhoids 23. Stool Diarrhea Constipation Undigested Food Mucous or Blood in stool 24. Genito-Urinary Tract Kidney Disease Painful Urination Frequent Urinary Tract Infections Frequent Urination Venereal Disease Kidney Stones Impaired Urination Urination at night Blood in Urine Incontinence 4

25. Female Reproduction Irregular cycles Breast lumps/tenderness Nipple Discharge Heavy Flow Clotting Bleeding between Cycles Vaginal Discharge Premenstrual Problems Menopausal Symptoms Post Menopause Difficulty Conceiving Pain with Intercourse 26. Menstrual/Birthing History Age of First Menses: #of Days of Menses: Length of Cycle: Birth Control Now: Birth Control Use in the Past: # of Pregnancies: # of Miscarriages: # of Abortions: # of Live Births: Are You Fertile? Y N Age at Menopause Vaginal Discharge 27. Male Reproductive Sexual Difficulties Prostrate Problems Testicular Pain/Swelling Penile Discharge Pain with Intercourse 28. Musculoskeletal Neck/Shoulder Pain Muscle Spasms/Cramps Arm Pain Upper Back Pain Mid Back Pain Low Back Pain Leg Pain Joint Pain Where: 29. Neurologic Vertigo/Dizziness Paralysis Numbness/Tingling Loss of Balance Seizures/Epilepsy 30. Endocrine Hypothyroid Hyperthyroid Hypoglycemia Diabetes Mellitus Night Sweats Feeling Hot or Cold Hot Flashes 31. Other Anemia Cancer Rashes Eczema/Hives Cold Hands/Feet 32. Lifestyle A. Food intake for yesterday: Breakfast: Lunch: Dinner: Snacks: B. Exercise: 5

C. When do you go to sleep? When do you awake? D. Do you have vivid dreams/nightmares: E. Occupation: Employer: Hours/week: Do you enjoy work? Y N Why/Not? F. Nicotine/Alcohol/Caffeine/Recreational drug use: How Often? G. Have you experienced any major traumas (emotional, spiritual, physical): Y N Please explain: H. Consumption of Liquids Type of fluid: Amount per day: I. Television Habits: J. Reading Habits: K. Interests and Hobbies: How did you hear of Ageless Acupuncture? Thank you for taking the time to fill out this form. I appreciate that this is a time investment for you and I want you to know that I use all of this information to arrive at my diagnosis and treatment plan. Cheryl McCarthy, L.Ac. 6

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