5 POINTS ACUPUNCTURE

Health History Questionnaire

Please help us provide you with a complete evaluation b taking the time to fill out this questionnaire carefully. All of your answers will be absolutely confidential. If you have questions please ask. If there is anything you wish to bring to

our attention which is not asked on this form, please note it in the comments section on the last page.

Name: Home # : Work/cell:

Street Age: Ht: Wti

City: State: Zip:

Occupation: Date of Birth: Marital Status:

Email (please print legibly):

Family Physician:

Emergency Contact:

Referred By:

Have you ever been treated by acupuncture or Oriental medicine before?

Ve call the day before appointments to confirm and occasionally email newsletters or other info about out clinic. Do we have permission to leave a voice message to confirm your appointment and to email you from the clinic? Y or N

MAIN PROBLEM(s) that you would like us to help with:

How long ago did this problem begin (be specific)?_

To what extent does this problem interefere with your daily activities(work, sleep, sex etc)?_

Have you been given a diagnosis for this problem? If so what?

What kinds of treatment have you tried?

Significant Ilnesses-Circle when appropriate: Cancer Diabetes Hepatitis High Blood Pressure Heart disease

Rheumatic Fever Thyroid Disease Seizures Venereal Disease Other

Surgeries:

Significant Trauma (auto accident, fails, etc.)

Your birth history (prolonged labor, forceps delivery, premature, etc.)

Allergies: (drug, chemicals, foods etc.)

Family Medical History (circle) Diabetes Cancer Higli Blood Pressure Heart Disease

Stroke Seizures Astlima Allergies (Other explain below)

Occupational Stress (chemical, physical, psychological etc.)

Do you exercise regularly? Please describe:

Have you ever been on a restricted diet? What kind?

Please describe your average diet. (Please be as specific as possible)

Morning Meal Afternoon Meal Evening Meal Snack

Do you smoke? If so, how many per day?

How many drinks of coffee, tea or soft drinks on average per week?

How much alcohol do you drink on average per week?

Please describe any use of drugs for non-medicinal purposes?

Please indicate painful or affected areas on charts below

Please check if you have had any of the following symptoms in the last three months:

G E N E R A L :

• Poor Appetite • Poor Sleeping • Fatigue • Fevers • Cliills • Night Sweats 0 Sweat Easily • Tremors • Cravings • Localized Weakness • Poor Balance • Changes in Appetite • Bleed or bruise easily 0 Weight Loss • Weight Gain 0 Peculiar tastes or smells • Strong Thirst • Sudden Energy Drop

Time of Day?

SKIN and Hair:

• Rashes • Ulcerations Any other skin or hair issues? • Itching • Eczema • Dandruff • Loss of hair • Change in hair or skin texture • Hives • Pimples • Recent Moles

HEAD, EYES, EARS, NOSE AND THROAT

• Dizziness • Concussions • Migraines

• Glasses • Eye Strain • Eye Pain • Poor Vision • Night Blindness • Color Blindness • Cataracts • Blurry Vision • Earaches • Ringing in ears • Poor Hearing • Spots in front of eyes

• Sinus Problems • Nose Bleeds • Recurrent sore throat • Grinding Teeth • Facial Pain • Sores on lips or tongue

• Teeth Problems • jaw Clicks

Headaches (where and when?)

Any other head or neck issue to discuss?

CARDIOVASCULAR:

• High Blood Pressure • Low Blood Pressure • Chest Pain • Irregular Heartbeat • Dizziness • Fainting • Cold hands or feet • Swelling of Hands • Swelling of Feet • Blood clots • Phlebitis • Difficulty Breathing

Any other heart or blood vessel issues to discuss?

RESPIRATORY:

• Cough • Coughing blood • Asthma

• Bronchitis • Pneumonia • Pain with deep breath • Difficulty breathing when • Production of phlegm-what

lying down color?

GASTROINTESTINAL:

• Nausea D Vomiting • Diarrhea • Constipation • Gas • Belching

• Black Stools • Blood in stools • Indigestion • Bad Breath • Rectal pain • Hemorrhoids • Abdominal pain or cramps • Chronic laxative use

Any other issues with your stomach or

intestines ?

GENITO-URINARY;

• Pain on urination • Frequent urination • Blood in urine • Urgency to urinate • Unable to hold urine • Kidney Stones • Decrease in flow • Impotency • Sores on genitals

Do you wake up to urinate? If so, how often?

Is there any particular color to your urine?

Any other issues with your genital or urinary system?

PREGNANCY AND GYNECOLOGY fwomen onlvl:

Number of Pregnancies Number of births Premature births

M i c r r r i p p c Abortions Age at first menses

Period between menses Last PAP

Duration First date of last menses Period between menses Last PAP

• Heavy or light menses • Vaginal Sores • Breast Lumps

• Irregular periods • Vaginal discharge • Breast tenderness

• Painful Periods • Clots • Changes in body or emotions

prior to menstruation?

Do you practice birth control? If so, what type and for how long?

• Heavy or light menses • Vaginal Sores • Breast Lumps

• Irregular periods • Vaginal discharge • Breast tenderness

• Heavy or light menses • Vaginal Sores • Breast Lumps

• Irregular periods • Vaginal discharge • Breast tenderness

MUSCULOSKELETAL:

• Neck Pain • Muscle Pain • Knee Pain • Back Pain • Muscle Weakness • Foot/Anke Pain • Hand/Wrist Pain • Shoulder Pain 0 Hip Pain • joint Pain/Which joints?

Any other joint or bone issues?

NEUROPSYCHOLOGICAL:

• Seizures • Areas of numbness • Concussions • Easy to Anger

• Dizziness • Lack of coordination • Depression • Easily susceptible to stress

• Loss of balance • Poor Memory • Anxiety

Have you been treated for emotional issues?

Have you ever considered or attempted suicide?

Any other issues you'd like to discuss?