[PDF]Patient Health History Questionnaire...
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Patient Health History Q uestionnaire
NAME______________________________________________________ TODAY’S DATE_______________________ ADDRESS___________________________________________________CITY________________ZIP_________________ PHONE: Preferred________________________________Other___________________________________________________ Age_________ Date of Birth___________________ E-Mail______________________________________________Would you like to receive our e-newsletter? Yes___ No___ Occupation________________________________________Employer__________________________________________ PHYSICIAN/Clinic___________________________________________________________________________________ EMERGENCY CONTACT_________________________________Phone______________________________________ How did you hear about us?____________________________________________________________________________ Have you previously received acupuncture? _________ Have you previously received massage? _________ Do you have a pacemaker? ___Yes ___No Do you wear: contact lenses?__________hearing aid?__________ Main condition/s you would like to resolve________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________
Time of Onset and Cause/s (if known) of your condition/s____________________________________________________ ___________________________________________________________________________________________________
Please list any diagnoses you have been given______________________________________________________________ What treatments have you tried, & did they help/worsen your condition?_________________________________________ ___________________________________________________________________________________________________ Your Past Medical History (please include month/year when the diagnosis was established) Cancer______ Hepatitis_____ Thyroid Disease_______Seizures________Fibromylagia_______ Tuberculosis______ Hypertension_______Blood Clots_____ Anemia_______ Arthritis_______ Breathing Problems_______ Diabetes_______ Heart Disease______ Digestive Disorders_______HIV/ Aids Positive_______Venereal Disease _______Broken Bones__________ Contagious Skin Disorder ______Open wounds____Bruise easily____Artificial Joint_____ MS_______ Parkinson’s__________ Other (please specify) __________________________________________________________________________ Surgeries / Hospitalization/Traumas (type and date) __________________________________________________________ ___________________________________________________________________________________________________
Allergies (including reactions to skin care products) ___________________________________________________________________________________________________ Medicines (prescribed & non-prescribed), Herbs, Vitamins, etc. taken consistently the last two months_________________
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Family Medical History (please specify family member) Cancer Diabetes Hepatitis Hypertension Heart Disease Stroke Asthma Alcoholism Miscarriage Psychiatric or Emotional Imbalance Other_________________________________________________________ Lifestyle Information: Height_____________Weight now ______________ Weight one year ago_______________Weight maximum___________ Occupational Stress? (chemical, physical, psychological) _____________________________________________________ Describe your average week’s exercise____________________________________________________________________ Are you on a restricted diet? No____ Yes____ Describe ____________________________________________________ Cigarette Smoking (brand, quantity, & years)______________________________________________________________ Do any other non-medical drugs?________________________________________________________________________ How much coffee, tea, cola & diet soda do you drink per week? _______________________________________________ How much water do you drink per day?_________________________________________________________________ How much alcohol do you drink per week? ________________________________________________________________ How many hours per day do you sleep?_______________Do you sleep well?_________________________________ On average, describe your energy level on a scale of 1-10(highest) _______________ List the three most significant events in your life. Are any of these situations continuing to impact your life?
____________________________________________________________________________________________________
Indicate Painful or distressed areas:
Do you have any difficulty lying on your front, back, or side? Yes No If yes, please explain
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Please check if you have or have had in the past three months any of the following diseases or conditions. o o o
Poor sleep/Insomnia Fatigue Fever
o o o
Chills Night Sweats Sweat easily
o o o
Bleed or bruise easily Strong thirst Sudden energy drop
o o o o o
Eczema Pimples/Acne Dandruff Dry Skin Recent moles or warts
o o o
Loss of Hair Changes in hair or skin Fungal Infections
o o o o o
Pain in muscles Difficulty Walking Cold hand/feet Swelling of hand/feet Spinal curvature
o o o o o
Hernia Numbness/Tingling Tremors Paralysis Sprain of joint
o o o o o o o
Blurry Vision Spots in vision Earaches Ringing in ears Poor hearing Sinus problems Nose bleeds
o o o o o o o
Sore throat Grinding teeth Teeth problems Facial pain Jaw clicks/ TMJ Sores on lips, tongues Difficulty swallowing
o o o
Palpitations Fainting Phlebitis
o o o
Irregular Heartbeat Varicose veins Other:
o o o o
Bronchitis Pneumonia Chest pain Esophageal pain
o Production of phlegmwhat color?__________
o o o o o o o
Blood in stools Indigestion/GERD Bad breath Rectal pain Hemorrhoids Abdominal pain Gallbladder problems
o o o o o o
Parasites Poor appetite Cravings Crohn’s Irritable Bowel/Colitis Peculiar taste
o o o o
Stress Bad temper Bi-polar Eating Disorder
o
Other psychiatric diagnosis
Skin/Hair o o o o o
Rashes Ulcerations Hives Itching Shingles
Musculoskeletal o o o o o
Rheumatoid Arthritis Osteoarthritis Tendonitis Osteoporosis Weakness in muscles
Head, eyes, ears, nose and throat o o o o o o o
Dizziness Concussions Migraines or headaches Eye strain or pain Night Blindness Poor Vision Cataracts
Cardiovascular o o o
High blood pressure Low blood pressure Chest pain
Respiratory o o o o
Cough Coughing blood Wheezing Difficulty breathing
Gastrointestinal o o o o o o o
Nausea/Vomiting Diarrhea Constipation Chronic laxative use Gas Belching Black stools
Neurological- Psychological o o o o
Loss of balance Lack of coordination Depression Anxiety
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Genito-urinary o o o o o
Pain on urination Frequent urination Blood in urine Urgent to urinate Kidney stones
o o
Frequent vaginal infections Pelvic infection Endometriosis Vaginal itching/discharge Fibroids
o o o o
o o
Unable to hold urine Chronic bladder infection Kidney infection Pause of urine flow
o o o o
Pain in genitals Itching of genitals Sores on genitals Other:
Ovarian cysts Irregular periods Clots Pain/cramps prior/during periods Breast tenderness Breast lumps
o o o
Fertility problems Hot flashes Moodiness related to periods
Female o o o o o
o o
_____number of pregnancies _____number of births
_____miscarriages _____abortions
_____premature births _____cesareans _____difficult delivery
First date of last period________________ Duration of periods ______days, cycle _____days Do you practice birth control? Yes
no
If yes, what type and for how long?______________________
Any chance you are pregnant? ___Yes ___No
Male o o o
Prostate problems Discharge Impotence
o o o
Frequent seminal emission Fertility problems Ejaculation problems
o o
Painful/swollen testicles Other____________
I understand the above information and guarantee this form was completed to the best of my knowledge. ____________________________________________________________Date______________ Signature o
Adult patient
o
Parent or Guardian
o
Spouse
Any other information you would like to give me?
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