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About Me
Schedule Appointment
FAQs
Gallery
Home
Contact
Blog
Health History Form
Have you ever been treated with acupuncture or Chinese Medicine?
*
Yes
No
What main problem would you like us to help you with?
*
What other medical treatment(s) or alternative therapies have you tried for this problem?
Do you currently have problems with any of the following?
Please check all that apply.
Allergies
Arthritis
Asthma
Cancer
Chronic infections
Diabetes
Eye disease
Fatigue
Food cravings
Gallbladder disease
Heart disease
Heartburn
Headaches/migraines
Hemorrhoids
High blood pressure
High cholesterol
Kidney disease
Kidney (or bladder) stones
Liver disease
Lung disorder
Menopausal symptoms
Mental illness
Numbness or tingling
Obesity
PMS
Poor circulation
Psoriasis, eczema, acne
Recent surgery
Recurrent infections
Recurrent sore throats
Sensitivities
Sinus congestion
Sprains or bruising
Stomach disorders
Substance abuse
Tuberculosis exposure
Tumor
Varicose veins
Other (describe below)
Other:
Do you smoke?
*
Yes
No
If yes, # of packages per day:
Do you drink coffee?
Yes
No
If yes, # of cups per day:
Do you drink alcohol?
Yes
No
If yes, # of drinks per day:
BRIEF HEALTH HISTORY
Please list all operations you've had and the years when you had them:
Please list all illnesses and/or injuries that required hospitalization and the corresponding years:
Please list any serious illnesses, injuries or accidents you've had:
Please list your medications, including supplements and over-the-counter medications:
Please include name, dosage, reason for taking it and length of treatment for each medication.
SYSTEMS REVIEW
Heart
Please check all that apply
Normal blood pressure
High blood pressure
Low blood pressure
Dizziness with standing
High cholesterol
Congenital disease
Palpitations
Valve disease/disorder
Headaches
Do you frequently have headaches?
Yes
No
If yes, check all that apply:
Cause visual problems
Awaken you at night
Pain is dull and achy
Pain feels like a tight band
Occur on the side or sides
Occur on the back
Occur on the front
Occur in the eye region
Occur on top
Medication helps
Medication does not help
Involve dizziness or weakness
Are aggravated by overworking
Head feels heavy
Occur in sinus area
If you experience frequent headaches, what is their duration?
Other headache-related concerns:
Pain
If you experience pain, where is it located?
Is your pain constant or intermittent?
Constant
Intermittent
Is it better or worse with heat?
Better
Worse
Is it dull and/or achy?
Yes
No
Is it better or worse with pressure?
Better
Worse
Is it better or worse with activity?
Better
Worse
Is it sharp and/or stabbing?
Yes
No
Is it better or worse with cold?
Better
Worse
Is there a heavy feeling?
Yes
No
What time of day is your pain the worst?
Pain intensity this past week (1-10)
Please provide further detail about your pain that hasn't already been covered or needs further explanation:
Thirst
Please check all that apply.
Thirsty often
Absence of thirst
Thirst with little desire to drink
No thirst, but drink a lot anyway
Dry mouth
Preference for cold drinks
Preference for room-temperature drinks
Preference for hot drinks
Other (describe below)
Other:
What do you drink throughout the day and in what quantities?
Appetite & Digestion
Please check all that apply.
Rapid hungering
Poor appetite
Hungry but no desire to eat
Not hungry but desire to eat
Nausea
Vomiting
Bloating
Gas/flatulence
Indigestion
Acid reflux
Preference for salty food
Preference for fatty foods
Preference for sweets
Bitter taste in mouth
Sweete taste in mouth
Sour taste in mouth
Loss of taste
Canker sores
Toothaches
Bad breath
Diverticulitis
Undigested food in stool
Eating disorder
Cravings
Urination
Please check all that apply.
Frequent
Urgent
Burning
Painful
Cloudy
Dark color
Foul smell
Bloody
Difficult start
Incontinence
Large amount
Small amount
Kidney stones
History of bladder/kidney infection
Other (describe below)
Other:
# of times a day:
Proportional to intake?
Yes
No
# of times at night:
Bowel Movements
Please check all that apply.
Constipation
Diarrhea
Loose stool
Watery
Incomplete
Hard and dry
Thin
Well formed
Strong smell
Mucus
Blood
Light to dark brown
Black
Yellow
Green
# of bowel movements a day:
Upper Respiratory
Please check all that apply.
Chronic cough
Bronchitis
Profuse, watery sputum
Thick sputum
Green sputum
Yellow sputum
Sore throat
Post nasal drip
Dry sinuses
Sinus infection
Swollen sinus
Congestion
Sinus headache
Wheezing
Snoring
Have you ever been tested for allergies?
Yes
No
If yes, what, if any, substances were you allergic to?
Vision
Please check all that apply.
Vision loss
Dry eyes
Excessive tearing
Eye pain
Red eyes
Swollen eyes
Eyelid drooping
Glaucoma
Cataracts
Macular degeneration
Flashes/floaters
Double vision
Burning eyes
Eye discharge
Itchy eyes
Hearing
Please check all that apply.
Hearing loss
Ear pain
High-pitched tinnitus
Low-pitched tinnitus
Clogged ears
Drainage
Vertigo
Other (describe below)
Other:
Skin
Please check all that apply.
Rashes
Eczema
Rosacea
Psoriasis
Acne
Prickly heat
Skin ulcers
Itching
Dry skin
Oily skin
Other (describe below)
Other:
Temperature
Please check all that apply.
Feel cold easily
Feel hot easily
Cold hands
Cold feet
Alternating hot and cold
Hot/cold flashes
Sensitive to weather changes
Sensitive to barometric changes
Cold weather bothers you
Hot weather bothers you
Damp weather bothers you
Windy weather bothers you
Sleep
Please check all that apply.
Wake feeling refreshed
Difficulty falling asleep
Difficulty falling back to sleep once wake up
Awakened easily
Difficulty waking up
Early morning waking
Dream-disturbed sleep
Unwanted movements
Awakened by pain
Sudden awakening
Nightmares
Susceptibility to fear and fright
Anxiety
Irritability
Poor memory
Palpitations
Night sweats
Can't stop thinking
Restlessness
Fatigue during day
Worry
# of hours of sleep each night:
Ideal hours of sleep each night for you:
REPRODUCTIVE (women only)
Age of first menses:
Are you having regular monthly periods?
Yes
No
If no, when and why did it stop?
Are you now or have you ever taken a birth control pill?
Yes
No
If so, when and for how long?
Have you ever had a miscarriage/stillbirth?
Yes
No
If yes, how many and when?
How many children born alive?
How many C-sections?
Please explain any pregnancy complications:
Do you have recurring yeast infections?
Yes
No
How many days per menstrual cycle?
How many days do you bleed?
Is your cycle regular?
Yes
No
Color of the flow:
Do you ever have clots?
Yes
No
If yes, what color are the clots?
Please describe the quantity of the flow on a scale of very light to very heavy:
What is the quality of the flow?
Thin
Normal
Thick
Do you have breakthrough bleeding?
Yes
No
If yes, how often and amount:
Do you have any type of pain with your period?
Yes
No
If yes, when and where?
What relieves the pain?
What makes the pain worse?
Describe the pain:
Do you have different emotions from normal around your period, and if so, please describe them and the timing of when they occur around your period:
Libido:
Low
Average
High
REPRODUCTIVE (men only)
Please check all that apply:
Loss of sexual function
Genital treatment
Hernia
Prostate disease
Erectile difficulty
Other (describe below)
Other:
Libido:
Low
Average
High
ENERGY
Please check all that apply.
Low
Up and down
Exhausted
Hyperactive
Nervous
Abundant
Memory changes
Normal
EMOTIONS
Please check all that apply.
Depression
Sadness
Panic attacks
Sensitive
Worry
Over excited
Angry
Anxiety
Irritability
Memory problems
Do you have any of the following?
Please check all that apply.
Bleeding gums
Bad breath
Hoarseness
Sore tongue
Nosebleeds
Fainting spells
Edema/swelling
Limb weakness
Convulsions
Unwanted weight loss
Trouble swallowing
Mouth sores
Dizzy spells
Hair loss
Thank you! Your Health History Form has been submitted.
