Patient Health History Questionnaire

[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_________________


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


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


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


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


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


Parent or Guardian



Any other information you would like to give me?