HEALTH HISTORY QUESTIONNAIRE

Important: Complete this document as thoroughly as possible.  Some of the questions that follow may seem unrelated to your condition, but may play a major role in diagnosis and treatment.

All information is strictly confidential.

I. GENERAL PATIENT INFORMATION                                                  Date: ____/____/_____

Name:                                                                                                                                                                                  

Address:                                                                                                                                                                              

City, State, Zip Code:                                                                                                                                                       

Home Phone:                                                                      Work Phone:                                                                      

Email address:                                                                                                                                                                  

Age: ______        Date of Birth: _____/_____/_______         Place of Birth:                                                    

Guardian (if under 18 years of age):                                                                                                                           

Gender: M F                  Height: ____’____”        Weight: _____ lbs.      Marital Status:                            

Occupation:                                                                        Employer:                                                                           

How did you hear about our office?                                                                                                                           

Family Physician:                                                                             Phone:                                                                  

Emergency Contact Name, Phone Number and Relation to Patient:

Have you ever been treated by Acupuncture or Oriental Medicine before?    Yes                         No

Main Conditions you would like us to help you with, in order of significance:

1.                                                                                                             4.

2.                                                                                                             5.

3.                                                                                                             6.

How long ago did these problem(s) begin, please be specific:

To what extent do these problems affect your daily activities, such as work, sleep or hobbies?

What kinds of treatment have you tried, and how have they worked?

Have you been given a diagnosis for any of these problems, if so, what?

II. PAST MEDICAL HISTORY

How was your childhood health?

List all Hospitalizations, Surgeries, Auto Accidents, Trauma, Falls:

Allergies (food, seasonal, environmental):

Recent Tests (Please indicate test results and date):

Physical               Cholesterol          Prostate                                Blood (which)                     HIV/STD

Pap Smear           Mammography                  Other: _______________________

Test Results and Date:                                                                                                                                                    

Circle any you have had in the past:

Diabetes               Allergies               Glaucoma            Rheumatic Fever                Heart Disease     CVA (Stroke)

Vein condition   Asthma                 Pneumonia          Tuberculosis                       Emphysema        Mumps

Jaundice               Gonorrhea           Syphilis                                Bleeding Tendency           Measles                High Fever

Meningitis           Chicken Pox        Epilepsy               Nervous Disorder             High Fever           Hepatitis

Mononucleosis  HIV/AIDS           Polio                      Thyroid Disorder              Paralysis              Cancer

Migraines            Diabetes               Hepatitis              High Blood Pressure        Lung Disorder    Liver Disorder

Kidney Disorder                                Spleen Disorder                 Stomach Disorder            

Other:                                                                                                                                                                                                   

Immunizations:

Family Medical History: Please circle all that apply in your immediate family

Cancer                  Diabetes               High Blood Pressure        Stroke                    Seizures                Allergies

Asthma                 Heart Disease     Other Major Illnesses:                                                                                     

III. PATIENT PROFILE

Please list all medications taken in the last 3 months (including drugs, vitamins and herbs):

Occupational Stress (chemical, physical, psychological, etc.):

Do you have a regular exercise program?                                 If yes, describe:

Are you on a restricted diet?                                                          If yes, describe:

How much water do you drink daily?

How many caffeinated drinks do you drink per week (coffee, tea, soda)?

Do you smoke?                   If yes, how many cigarettes per day?

Pain Conditions:

Indicate any areas of pain in the body and the location of any scars on the body:

Is the pain sensation: 

Sharp                    Burning                Aching                  Cramping            Dull       Moving                 Fixed    

Other:

Do any of the following lessen the pain:

Pressure                               Cold                       Heat                       Exercise                Other:

 Do any of the following worsen the pain:

Pressure                               Cold                       Heat                       Exercise                Other:

 Please check the following that pertain to you:

 Overall Temperature (Kidney Function):

 Hot body temperature or sensation          Cold hands      Sweaty hands                                 Afternoon flushes

 Cold body temperature of sensation       Cold feet             Sweaty feet                       Night sweats

 Heat in the hands, feet and chest              Hot flashes any time of the day                 Lack of perspiration

 Perspire easily                Thirsty: for hot or cold drinks

Overall Energy (Lung and Kidney Function):

 Difficulty keeping eyes open in the daytime         Shortness of breath        General weakness

 Easily catch colds                          Low Energy     Feel worse after exercise

 Overall Blood Function:

 See floaters or floating black spots in the eyes      Recent moles, unusual moles

 Freckles             Dizziness         Pimples

 Heart Function:

 Cardiovascular disease               High blood pressure     Low blood pressure

 Chest pain        Fainting            Palpitations                     Sores on tip of tongue

 Restlessness    Anxiety             Hard to fall asleep         Wake unrefreshed       

 Nightmares      Restless sleep  Mental Confusion          Restless dreaming

 Waking during the night             Chest pain traveling to shoulders or down arms

 Lung Function:

 Profuse nasal discharge:            thin/clear/runny            thick/white         thick/yellow

 Cough: Wet or Dry         Nose Bleeds     Sinus Congestion           Dry mouth

 Dry, itchy throat             Sore throat        Dry skin                            Allergies: to what?

 Sneezing                           Hives                                 Stiff neck                           Stiff shoulders

Bronchitis                         Rashes               Itching                               Eczema

 Dandruff                           Sadness             Melancholy                     Difficulty inhale or exhale

 Alternating fever and chills        Achy feeling in the body             Smoke cigarettes                            

 Spleen Function:

 Low appetite                   Changes in appetite                      Cravings, for what?

 Abrupt weight gain       Abrupt weight loss                        Abdominal bloating

 Abdominal gas               Stomach Gurgling                         Fatigue after eating

 Easily bruised                 Hemorrhoids                                   Pensive/Over-thinking

 Worry                                Prolapsed organs: which organ?

 Spleen, Stomach, Large Intestine, Small Intestine Function:

 Loose Stools                     Incomplete Bowel Movements   Constipation

 Diarrhea                           Blood in Stools                                                Undigested food in stools

 Mucous in stools            Black or tarry stools      Chronic use of laxatives: what type of laxative?

 Dampness trapped in body:

 General sensation of heaviness in body                 Mental heaviness           Mental sluggishness

 Mental fogginess            Swollen hands                Swollen feet                     Swollen joints

 Chest congestion            Nausea                              Snoring                             Dizziness

 Snoring                             Phlegm production

 Stomach Function:

 Burning sensation after eating                  Large appetite                 Bad breath        Vomiting

 Sores on lips, tongue or mouth  Ulcer (if diagnosed)       Belching            Acid regurgitation

 Cold sensation in stomach                         Hiccoughs                        Stomach Pain  Heartburn      

 Bleeding, swollen or painful gums

 Liver and Gallbladder Function:

Chest pains                      Tight sensation in chest               Bitter taste in mouth

Anger easily                    Frustration                                       Depression

Irritability                         Skin rashes                                      Tingling sensations

Numbness                        Muscle Spasms                               Muscle Twitching

Muscle Cramping          Seizures                                            Convulsions

Lump in throat               Teeth Grinding                               Alternating diarrhea and constipation

Neck tension                   Shoulder tension                            Hip pain/Sciatica

Drink alcohol                  Recreational drugs (which, how much per week?)

High pitch ringing in the ears                                                   Gallstones, history of or currently

Sexually transmitted diseases (which)                                   Genital sores

Frequently unable to adapt to stress (what causes this stress?)

 Headaches: How Often? Describe location:

Migraines

 Eyes: (Liver Function)

 Itchy                   Red or Bloodshot                           Hot                                     Dry

 Watery               Gritty or sandy feeling                 Blurry vision                   Decreased night vision

 Near-sighted   Far-sighted                                       Cataracts                          Visual Disturbances

 Kidney, Urinary Bladder Function:

 Frequent cavities            Easily Broken Bones     Poor hearing                    Earaches

 Painful knees                  Weak knees                      Cold in knees                  Low back pain

 Memory problems          Excessive hair loss        Pre-mature grey hair     Low-pitch ringing in the ears

 Kidney stones                 Bladder infections         Fear                                    Easily startled

 Foot or ankle weakness or pain                                 Lack bladder control     Sneeze or jump incontinence

Urination:

How many times per day do you urinate?

Do you wake during the night to urinate?                How many times per night?

 Normal color urine        Dark yellow                     Clear                                  Reddish

 Cloudy                              Scanty                                Profuse                              Strong Odor

 Burning                             Painful                              Difficult                             Urgent

 Libido:
 Normal              High                   Low

 Women only:

Do you practice birth control?                       What type and for how long?

Pregnant? Y N                             Is there a chance you may be pregnant now?

Vaginal discharge:            Frequent?                            Color?                                   Odor?

Regular menstrual cycle? Y N                               

Number of children: _____                                            Number of pregnancies: _____                    

Age of first menstruation: _____                                  Age of menopause (if applicable):_____

Average number of days of flow: _____                     Average number of days of entire cycle: _____

Uterine bleeding/spotting between periods? Y N           How much and how often?

 Do you experience any of the following pre-menstrual syndromes?

 Nausea                              Vomiting                           Water retention               Breast swelling

 Food cravings                 Headaches                       Migraines                         Breast tenderness

 Depression                       Irritability                         Anxiety                             Other emotions: ____________

 Dull pain, where? __________________               Sharp pain, where?                                                                     

 Please fill in the following menstrual chart:

 Men only:

 Swollen testes                 Testicular pain               Impotence                         Premature ejaculation

Feeling of coldness or numbness in external genitalia                      Other_________________

 All please fill out:

 Please describe your Average Daily Diet:

Breakfast                                                              Lunch                                                   Dinner

Snacks (eaten at what time?):

Please tell us of any other problems you would like to discuss:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        

Patient Signature: _____________________________________

Acupuncturist Signature: _______________________________________

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