<p> Four Corners Acupuncture Clinic Health History Questionnaire Date______</p><p>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.</p><p>Name______Date of Birth______Age______</p><p>Gender: Male Female Transgender IntersexEmail Address ______</p><p>Address______City______State______Zip______</p><p>Home Phone______Work Phone______Cell Phone______</p><p>Height______Weight______Occupation______</p><p>Family Physician______Last seen (date)______Referred by______</p><p>Emergency Contact______Emergency Contact Phone______</p><p>Relationship status (optional)  Single Married/Partnered  Separated  Divorced  Widowed</p><p>Have you been treated by Acupuncture or Chinese Medicine in the past? Yes No ______</p><p>What is/are the main problem(s) you would like help with? ______</p><p>How long ago did this problem begin? ______</p><p>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? ______</p><p>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______</p><p>Other (include chronic illnesses) ______</p><p>Surgeries (type of and date)______</p><p>Significant trauma or hospitalizations (auto accidents, falls, concussions, etc.)______</p><p>Have you used antibiotics in the past? ______</p><p>Birth History (prolonged labor, forceps delivery, breech, etc.)______</p><p>Are you currently pregnant?______What is your due date? ______</p><p>Allergies (drugs, chemicals, foods) ______</p><p>What is your reaction? ______</p><p>Family Medical History: Cancer______High Blood Pressure_____ Thyroid Disease_____ Seizures_____ Heart Disease______Diabetes______Other______Anemia______Asthma______Hepatitis______</p><p>Medicines taken within the last two months (prescription, over the counter, vitamins, herbs, etc.) Attach list if needed.</p><p>______</p><p>______</p><p>Occupational Stress (chemical, physical, psychological, etc.)______</p><p>______</p><p>Do you have a regular exercise program? Yes No Please describe______</p><p>______</p><p>Have you ever been on a restricted diet? Yes No Please describe______</p><p>______</p><p>Please describe your average daily diet:</p><p>Morning______</p><p>Afternoon______</p><p>Evening______</p><p>Do you smoke? Yes No How many packs per day? ______</p><p>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______</p><p>Please Rate the Following:</p><p>Great Good Fair Poor Bad Comments</p><p>Spouse Family Living Situation Diet Sex Life</p><p>Self Work</p><p>Exercise Spirituali ty</p><p>Please check any symptoms you have had in the last three months:</p><p>General __ Sweat easily  __ Headaches? __ Pain: Where:______Night sweats When?______</p><p>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 </p><p>__ 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</p><p> 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</p><p>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:</p><p>No problem Worst imaginable</p><p>Please note the greatest degree of severity of your main problem within the last week:</p><p>No problem Worst imaginable</p><p>Indicate painful or distressed areas:</p><p>Front Back</p><p>Comments: (Please indicate any other problem you would like to discuss): ______</p>