Spirit Path Acupuncture

Spirit Path Acupuncture Health History Questionnaire

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:

Address: City: State: Zip:

Home Phone: Cell Phone: Email:

Height: Weight: Occupation:

Family Physician: Referred by:

Emergency Contact: Emergency Contact Phone:

Relationship status (optional): Single  Married/Partnered Separated  Divorced Widowed

Have you been treated by acupuncture or Traditional Chinese Medicine before?  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?

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

What kinds of treatment have you tried?

Past Medical History: Cancer_____ High Blood Pressure_____ Thyroid Disease_____ (please include date) Seizures _____ Rheumatic Fever _____ Heart Disease _____ Hepatitis _____ Venereal Disease _____ Diabetes _____

Other:

Surgeries (type of and date):

Significant Trauma (auto accidents, falls, etc.):

Significant Dental Work (type and date):

Birth History (prolonged labor, forceps delivery, etc):

Allergies (drugs, chemicals, foods/results):

Family Medical History (check):  Diabetes  High Blood Pressure Stroke Asthma  Cancer  Heart Disease Seizures Allergies  Other:

Medicines taken within the last two months (vitamins, drugs, herbs, etc.):

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 What kind?

Please describe your average daily diet: Morning:

Afternoon:

Evening:

How many packs of cigarettes do you smoke per day? How much coffee, tea or cola do you drink per week? How much alcohol do you drink per week? Please describe any use of drugs for non-medical purposes:

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

General q Peculiar tastes or smells q Poor sleeping q Chills q Strong thirst (cold or hot) q Tremors q Fevers q Thirst, no desire to drink q Poor balance q Sweat easily q Fatigue q Cravings q Night sweats q Sudden energy drop q Change in appetite q Localized weakness Time of day? q Poor appetite q Bleed or bruise easily q Edema q Weight gain Where: q Weight loss q Urgency to urinate Skin and Hair Cardiovascular q Frequent urination q Rashes q High blood pressure q Blood in urine q Itching q Low blood pressure q Decrease in flow q Change in hair or skin q Chest discomfort/pain q Unable to hold urine q Ulcerations q Heart palpitations q Dribbling q Eczema q Cold hands or feet q Kidney stones q Oozing on skin lesion q Swelling of hands q Impotency q Hives q Swelling of feet q Change of sexual drive q Pimples q Blood clots q Sores on genitals q Recent moles q Fainting q Do you wake up to q Loss of hair q Difficulty in breathing urinate? q Yes q No q Dandruff q How often: Other heart or blood vessel Other hair or skin problems: problems q Any particular color to your urine?

Other genital or urinary system problems:

Head, Eyes, Ears, Nose and Respiratory Throat q Shortness of Breath (SOB) q Cough Pregnancy and Gynecology q Dizziness q Number of pregnancies: q Migraines q Asthma/wheezing

q Headaches q Pain with a deep breath When: q Difficulty in breathing when q Number of births: Where: lying down q Number of premature q Facial pain q Production of phlegm. births: q Glasses What color: q Number of miscarriages: q Poor vision q Coughing blood q Night blindness q Pneumonia q Number of abortions: q Blurry vision q Bronchitis q Color blindness Other lung problems: q Age at first menses: q Blind field q Spots in front of eyes q Period between menses q Eye pain (days): q Eye strain q Duration of menses q Cataracts (days): q Eye dryness Gastrointestinal q Bad breath q First day of last menses: q Excessive tear q Discharge from eyes q Nausea q Vomiting q Heavy periods q Poor hearing q Light periods q Ringing in ears q Heartburn q Belching q Painful periods q Earaches q Irregular periods q Discharge from ear q Indigestion q Diarrhea q Changes in body/psyche q Nose bleeds prior to menstruation q Sinus congestion q Constipation q Chronic laxative use q Clots q Nasal drainage q Menopause: q Grinding teeth q Blood in stools q Black stools Age: Year: q Teeth problems q Vaginal discharge q Jaw clicks q Abdominal pain or cramps q Gas q Postcoltal bleeding q Concussions q Vaginal sores. Date of last q Recurrent sore throats q Rectal pain q Hemorrhoids Pap: q Hoarseness q Breast lumps q Sores on lips or tongue Other stomach or intestinal q Nipple discharge q Do you practice birth Other head or neck problems problems: control? q Yes q No What type and for how long?

Genito-Urinary

q Pain on urination q Areas of numbness Musculoskeletal q Weakness Have you ever been treated for q Neck pain q Sleep disorder emotional problems? q Shoulder pain q Concussion qYes q No q Back pain q Bad temper q Elbow pain q Loss of control/violence Have you ever considered or q Hand/wrist pain potential attempted suicide? q Hip pain q Vertigo qYes q No q Knee pain q Lack of coordination q Foot/ankle pain q Depression Other neurological or q Muscle pain q Easily susceptible to psychological problems q Muscle weakness stress q Loss of balance q Poor memory Neuropsychological q Seizures q Anxiety q Substance abuse Please note the degree of severity of your problem now:

I------I No Problem Worst Imaginable

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

I------I No Problem Worst Imaginable

Indicate painful or distressed areas:

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