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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