Four Corners Acupuncture Clinic

Four Corners Acupuncture Clinic Health History Questionnaire Date______

Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All of your answers will be held absolutely confidential. If you have any questions, please ask. Thank you.

Name______Date of Birth______Age______

Gender: Male Female Transgender IntersexEmail Address ______

Address______City______State______Zip______

Home Phone______Work Phone______Cell Phone______

Height______Weight______Occupation______

Family Physician______Last seen (date)______Referred by______

Emergency Contact______Emergency Contact Phone______

Relationship status (optional)  Single Married/Partnered  Separated  Divorced  Widowed

Have you been treated by Acupuncture or Chinese Medicine in the past? Yes No ______

What is/are the main problem(s) you would like help with? ______

How long ago did this problem begin? ______

To what extent does this problem interfere with your daily activities? ______H ave you been given a diagnosis for this problem? If so, what? By whom? ______

What kinds of treatment have you tried? ______Past/Current Medical History: Cancer______High Blood Pressure_____ Thyroid Disease______(please include date) Seizures_____ Rheumatic Fever______Heart Disease______Hepatitis_____ Venereal Disease______Diabetes______HIV______Asthma/Pneumonia______Anemia______

Other (include chronic illnesses) ______

Surgeries (type of and date)______

Significant trauma or hospitalizations (auto accidents, falls, concussions, etc.)______

Have you used antibiotics in the past? ______

Birth History (prolonged labor, forceps delivery, breech, etc.)______

Are you currently pregnant?______What is your due date? ______

Allergies (drugs, chemicals, foods) ______

What is your reaction? ______

Family Medical History: Cancer______High Blood Pressure_____ Thyroid Disease_____ Seizures_____ Heart Disease______Diabetes______Other______Anemia______Asthma______Hepatitis______

Medicines taken within the last two months (prescription, over the counter, vitamins, herbs, etc.) Attach list if needed.

______

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

______

Do you have a regular exercise program? Yes No Please describe______

______

Have you ever been on a restricted diet? Yes No Please describe______

______

Please describe your average daily diet:

Morning______

Afternoon______

Evening______

Do you smoke? Yes No How many packs per day? ______

How much coffee, tea or cola do you drink per week? Coffee______Tea______Cola______How much alcohol do you drink per week? ______Please describe any use of drugs for non-medical purposes______

Please Rate the Following:

Great Good Fair Poor Bad Comments

Spouse Family Living Situation Diet Sex Life

Self Work

Exercise Spirituali ty

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

General __ Sweat easily  __ Headaches? __ Pain: Where:______Night sweats When?______

Level (1 - __ Bleed or bruise easily Where?______10)______Time of day______Facial Pain __ Energy level (1 - __ Edema __ Glasses 10)______Where?______Poor vision __ Sudden energy drop __ Tremors __ Night blindness Time of day______Poor balance __ Blurry vision __ Localized weakness __ Weight Gain __ Color Blindness Where______Weight Loss __ Blind field __ Fatigue __ Spots in front of __ Poor sleep Head, Eyes, Ears, Nose & eyes/floaters __ Sleep disorder Throat __ Eye Pain __ Fevers  __ Dizziness __ Eye Strain __ Chills  __ Migraines __ Cataracts __ Eye dryness __ Fainting __ Blood in urine __ Excessive tear __Other heart or blood __ Decrease in flow __ Discharge from eyes vessel problems? __ Dribbling __ Poor hearing ______Kidney stones __ Ringing in ears ______Do you wake up to __ Earaches urinate? __ Discharge from ear Yes___ No___ __ Hearing aide How often? ______Nose Bleeds Urine any particular color? __ Sinus congestion ______Nasal drainage __Other genital /urinary __ Loss of consciousness Respiratory systems __ Grinding teeth __ Allergies problems? __ Teeth problems __ Cough ______Jaw clicks __ Asthma/wheezing __ Pain with a deep breath ______Concussions __ Recurrent sore throats __ Shortness of breath __ Difficulty inhaling Diet/Gastrointestinal __ Hoarseness __ Peculiar taste or smells __ Sore on lips or tongue __ Difficulty exhaling __ Production of phlegm __ Strong thirst (cold or hot) Other head or neck __ Thirst, no desire to drink problems? What color? ______Cravings? For what? ______Coughing blood __ Change in appetite Skin and Hair __ Pneumonia __ Bronchitis __ Poor appetite __ Rashes __ Bad Breath __ Itching __ Other lung problems? ______Digestive Allergies __ Change in hair or skin __ Nausea __ Ulcerations ______Vomiting 

__ Eczema __ Heartburn  __ Oozing or skin lesion Musculo-Skeletal __ Belching __ Hives __ Neck pain __ Indigestion __ Pimples __ Shoulder pain __ Diarrhea __ Recent moles __ Back pain __ Constipation __ Loss of hair __ Elbow pain __ Chronic laxative use __ Dandruff __ Hand/wrist pain __ Blood in stools __ Foot fungus __ Hip pain __ Black stools Other hair, skin or foot __ Knee pain __ Abdominal pain or problems? cramps __ Foot/ankle pain ______Muscle pain __ Abdomen tense or firm __ Muscle weakness __ Abdominal distention ______Other muscular/skeletal __ Epigastric pain

problems? Pain better__ or worse__ Cardiovascular ______with pressure __ High blood pressure __ Gas ______Low blood pressure __ Rectal pain __ Chest discomfort/pain Urinary __ Hemorrhoids __ Heart Palpitations Other stomach or intestinal __ Cold hands or feet __ Pain on urination __ Urgency to urinate problems? __ Swelling of hands ______Swelling of feet __ Frequent urination __ Blood clots __ Profuse urination __ Retention of urination Psycho-emotional __ Insomnia __ Heavy periods __ Light __ Prostate problems __ Irritability periods __ Premature ejaculation or __ Loss of control/violence Color of blood: wet dreams potential __ Bright red __ Normal __ Other issues? Yes___ __ Depression red No______Easily susceptible to __ Purple __ Dark stress Brown Other __ Anxiety __ Painful periods ______Substance abuse __ Irregular periods ______Have you ever been __ Changes in body/psyche ______treated for prior to ______emotional problems? menstruation? How? ______Yes___ No______Have you ever considered ______or __ Clots ______attempted suicide? __ Menopause ______Yes___ No___ Age_____ Year______Vaginal discharge __ Postcoital bleeding __ Vaginal sores __ Date of last pap smear ______Breast lumps Neurological __ Nipple discharge __ Seizures __ Other issues? Yes___ __ Areas of numbness No___ __ Weakness ______Concussion/loss of ______consciousness __ Vertigo or dizziness __ Lack of coordination __ Loss of balance __ Poor memory

Sexual/Genital __ Changes in sexual drive Pregnancy __ Sores on genitals Number of __ Pain in genital area pregnancies______Do you consider your libido Number of normal for your age? Yes__ births______No__ Number of Too high__ Too low__ premature______Number of Female miscarriages______Age of first menses Number of abortions______Do you use birth control? __ Days between menses Yes___ No___ What type? ______Number of Days ______First day of last menses Male ______Impotence Please note the degree of severity of your main problem now:

No problem Worst imaginable

Please note the greatest degree of severity of your main problem within the last week:

No problem Worst imaginable

Indicate painful or distressed areas:

Front Back

Comments: (Please indicate any other problem you would like to discuss): ______