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Have you had acupuncture before?
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If yes, what for?
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How did you find us?
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If referral or other, please specify:
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Marital Status
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Number of Children
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Place of Birth (City/State/Country)
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Employment Status
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Occupation (if employed)
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Employer (if employed)
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PERSONAL HEALTH HISTORY
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Condition (Select all that apply)
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If condition not listed, please specify:
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Drug Allergies (Select all that apply)
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If drug allergy not listed, please specify:
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Food Allergies (Select all that apply)
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If food allergy not listed, please specify:
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FAMILY HEALTH HISTORY
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Mother (Select all that apply)
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If condition not listed, please specify:
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Father (Select all that apply)
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If condition not listed, please specify:
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Sister (Select all that apply)
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If condition not listed, please specify:
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Brother (Select all that apply)
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If condition not listed, please specify:
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Grandmother (Select all that apply)
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If condition not listed, please specify:
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Grandfather (Select all that apply)
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If condition not listed, please specify:
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MAJOR HOSPITALIZATIONS
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1. Operation or Illness
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Year of visit
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2. Operation or Illness
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Year of visit
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3. Operation or Illness
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Year of visit
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PREGNANCIES (If applicable)
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Currently Pregnant?
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How many total pregnancies?
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Living?
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Ectopic?
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Miscarriages?
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Induced Abortions?
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MEDICATION & SUPPLEMENTS
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Medication (Select all that apply)
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If medication not listed, please specify:
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Vitamins (Select all that apply)
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If vitamin not listed, please specify:
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Herbal Supplements (Select all that apply)
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If supplement not listed, please specify:
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HABITS
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Coffee or Caffeine beverages
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Cigarette or Tobacco
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Alcohol
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Marijuana
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If habit not listed, specify type and frequency:
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TRAVEL HISTORY
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Foreign travel within the last 6 months?
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If yes, what country or region?
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Reason for travel?
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Any illness during or after travel?
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If yes, describe illness:
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