Acupuncture Patient Health History

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Transcription:

Acupuncture Patient Health History Name: (first) (middle) (last) Today s Date: / / Date of Birth: / / Age: Gender/Preferred pronoun: Marital status (please circle one): Single Married Domestic Partnership Divorced Widowed Other 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 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. Draw a line where you have any scars from surgeries or injuries. 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 Emotional (please check any that you experience now): Mood Swings Anxiety/ Nervousness Mental Tension Depressive feelings Eating disorder Seasonal depression Energy and Immunity Fatigue Thyroid problems Heat intolerance Cold intolerance Slow Wound Healing Chronic Infections Cold hands and feet Anemia Hypoglycemia Excess thirst/ hunger Diabetes Insomnia Autoimmune Disease Specify: Hyperthyroid Hypothyroid Allergies Hay fever Swollen glands Night Sweats Ear, Nose, and Throat Impaired Hearing Ear Ringing Earaches 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 No Appetite Nausea Vomiting Epigastric Pain Passing Gas Heartburn Blood/ black stool Cramping Abdominal Pain Belching Hepatitis B or C Hemorrhoids Diarrhea Crohn s Disease Constipation Genito-Urinary Tract Kidney Disease Kidney Stones Painful Urination Incontinence Frequent Urination Urination at Night Retained Urination Blood in Urine Skin Eczema Hives Psoriasis Shingles Acne Rosacea Fungal infection Warts Other: Neurologic Vertigo/Dizziness Muscle weakness Paralysis Numbness/Tingling Loss of Balance Loss of memory Seizures/Epilepsy 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 Night sweats 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 Mark any organs that have been removed: Gallbladder - Date: Tonsils - Date: Appendix - Date: Other - Date: Male Reproductive Sexual Difficulties Testicular Pain Hernias Low libido Low testosterone Prostate Cancer Penile Discharge Impotence Swelling of scrotum 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

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