Acupuncture Patient Health History Name: (first) (middle) (last) Today s Date: / / Date of Birth: / / Age: Gender: Marital status (please circle one): Single Married Domestic Partnership Divorced Widowed Address: Phone (cell): Phone (other, specify): Do we have your permission to leave a message in regards to your care at one of the above numbers (please circle)? Yes for both No Only at: E-mail Do we have permission to send you updates and newsletters via email? Y N Occupation/Employer: Have you had Acupuncture therapy in the past? Please list practitioner(s): Primary Physician: Phone: Emergency Contact Name: Phone #: HEALTH CONCERNS CONDITION 1: CONDITION 2: CONDITION 3: Please identify the health concerns that have brought you today in the order of importance below. Entered: / / By: 1
Are you allergic/intolerant to any of the following (if yes, please specify and include reaction): Pharmaceuticals: Foods: Herbs: Other: Please list ALL medications (prescribed and over-the-counter), vitamins, and supplements you are currently taking and start date: MEDICINE DOSAGE REASON START DATE PRESCRIBER: LAST CHECK-UP: Do you have any reason to believe you may be pregnant? Y N If so, how far along are you? PERSONAL MEDICAL HISTORY Height: Weight: Currently: Past Maximum: When? Have you experienced any significant weight changes within the last year? Blood Pressure: What is your most recent blood pressure reading? / Date: Hospitalizations and Surgeries: X-Rays/CAT Scans/MRI s/nmr s/special Studies: Event: Date: Event: Date: Do you have a PACEMAKER? Y N 2
Musculoskeletal (Please circle any that you experience now:) Neck/Shoulder Pain Muscle Spasms/Cramps Arm Pain Upper Back Pain Mid Back Pain Low Back Pain Leg Pain Joint Pain (if so, where?): Please mark an x on the places where you currently have pain. Scars Draw a line on the diagrams where you have any scars from surgeries or injuries or list significant scars (with locations) below: Emotional (please check any that you experience now) Mood Swings Anxiety/ Nervousness Depressive feelings Panic attacks Seasonal depression Eating disorder Autoimmune and Inflammatory Conditions Hashimoto s Thyroid problems Heat intolerance Cold intolerance Slow Wound Healing Chronic Infections Cold hands and feet Anemia baldness Cellulitis Rheumatic fever Hx of strep infections Autoimmune Disease specify: Arthritis Plantar Fasciitis Food allergies Environmental allergies Swollen glands Head and Eyes Headaches Migraines Head Injury, date(s): Impaired Vision Eye Pain/Strain Glaucoma Cataracts Glasses/Contacts Tearing Poor night vision Dry eyes History of stys Light sensitivity Macular Degeneration: Wet or dry Ear, Nose, and Throat Impaired Hearing Ear Ringing Ear pain Ear discharge Sinus Problems Nose Bleeds Frequent Sore Throat Teeth Grinding TMJ/Jaw Problems Hay Fever Respiratory Pneumonia Frequent Colds Difficulty Breathing Emphysema Persistent Cough Chronic staph/strep Asthma/wheezing Shortness of Breath Bronchitis Coughing up blood Do you use a CPAP @ night? Y N Other respiratory problems: Outlook How do you feel about the following areas of your life? (5 = Great 4 = Good 3 = Fair 2 = Poor 1= Bad) Self 5 4 3 2 1 Significant Other 5 4 3 2 1 Family 5 4 3 2 1 Spirituality 5 4 3 2 1 Diet / Exercise 5 4 3 2 1 Sex 5 4 3 2 1 Work 5 4 3 2 1 3
Cardiovascular Fast pulse (>100 bps) Slow pulse (< 60 bps) Shortness of breath Chest Pain Dizziness Fainting High Blood Pressure Poor circulation Palpitations/Fluttering Stroke Heart Murmurs Rheumatic Fever Varicose Veins Swelling of Ankles Easy bruising Deep leg pain Heart Disease Blood clots Gastrointestinal Ulcers Nausea Epigastric Pain Heartburn Cramping Belching Hemorrhoids Crohn s Disease Constipation Genito-Urinary Tract Kidney Disease Painful Urination Frequent Urination Impaired Urination Skin No Appetite Vomiting Passing Gas Blood/ black stool Abdominal Pain Hepatitis B or C Diarrhea Diverticulitis Colitis Kidney Stones Incontinence Urination at Night Blood in Urine Eczema Hives/rashes Psoriasis Shingles Acne Rosacea Fungal infection Warts Other: Neurologic Vertigo/Dizziness Paralysis Loss of Balance Seizures/Epilepsy Muscle weakness Numbness/Tingling Loss of memory Male Reproductive Sexual Difficulties Prostrate Cancer Testicular Pain Penile Discharge Hernias Impotence Premature ejaculation Low libido Low testosterone Swelling of scrotum Female Reproductive Irregular Cycles Clotting Painful menses PMS Cramps Breakthrough bleeding Heavy Flow Painful Periods Endometriosis Vaginal Discharge Spotting PCOS Breast tenderness Pain w/ovulation Nipple Discharge Irritability Hot flashes Age of First Menses: # of Days of bleeding: # of days spotting: Total cycle days: Birth Control Type: # of Abortions: # of Pregnancies: # of Live Births: # of Miscarriages: Age of Menopause: Hysterectomy? Y N Date: Details of surgery: Current/previous use of Hormone Replacement therapy? Y N Breast implants? Y N Breast reduction? Y N History of illness while abroad? Y N What illnesses were identified (if any) and what was the treatment: History of alcohol/drug use: Y N Mark any organs that have been removed: Gallbladder - Date: Tonsils - Date: Appendix - Date: 4
MENSTRUATION CHART Please fill in the following chart Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Color (Normal=N, bright red=br, pale=p, brown=b, dark, purple=dp) Amount of flow (Normal=N, heavy=h, Light=L) Pain/Cramps (Location: abdomen or low back, Quality: dull, sharp) Clots (mark with an x ) Nausea/Vomiting (mark with an x ) Other FAMILY HEALTH Please write out any major illnesses that run in your family (heart disease, diabetes, blood disorders, blood pressure, neurological disorders, psychological disorders, orthopedic disorders, etc) and who had the condition: LIFESTYLE a. How many meals a day do you eat? b. Exercise: c. How many hours per night do you sleep? Do you wake rested? Y N d. Nicotine/Alcohol/Caffeine in a week (Y/N, how much?) e. How many 8oz glasses of water do you drink per day? What other fluids do you usually drink during the day? f. Spiritual/meditation practice: g. Is there anything else we should know? How did you hear about us? Who can we thank for your referral J : 5