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Where did you find us?
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Who referred you?
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Which specialists do you see?
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Specialist Additional Comments
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Have you had Acupuncture before?
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If so, please list where:
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Have you had Chinese herbal medicine before?
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If so, please identify which types:
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Emergency Services Member?
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Emergency Services Agency Details
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Medical History
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Please list any medications you are taking.
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Please list any supplements you are taking.
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Please list any herbs you are taking.
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Taken more than 2 courses of antibiotics.
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Recently traveled outside the country.
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If so, please indicate countries and dates.
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Taken adrenal corticosteroids.
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Unexpected rapid weight changes?
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Innoculations
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Innoculation Details
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Pet Allergies
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Additional Comments?
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Female Reproductive
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Reproductive
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Reproductive Additional Comments
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Age of First Menses
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Date of Last Known Menstrual Period
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Date of Last Menses
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Date of Last Pap Test
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Menstrual Duration (days)?
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Do you take Birth Control?
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Review of Systems
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Temperature
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Temperature Additional Comments
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Perspiration
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Perspiration Additional Comments
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Appetite/Thirst
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Appetite/Thirst Additional Comments
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Digestion
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Digestion Additional Comments
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Stool
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Stool Additional Comments
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Genitourinary
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Genitourinary Additional Comments
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Psychological
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Psychological Additional Comments
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General Health
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Energy Level (Scale of 0 to 10)
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Stress Level (Scale of 0 to 10)
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Sleep Assessment
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Sleep Assessment Additional Comments
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Describe Your Typical Breakfast
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Describe Your Typical Lunch
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Describe Your Typical Supper
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Describe Your Food Cravings
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Does Your Normal Diet Include?
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Weekly Exercise (times per week)
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Exercise Description
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What is your Occupation?
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Percent of Occupation Spent Sitting
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Percent of Occupation Lifting Heavy Objects
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Percent of Occupation Spent Standing
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Percent of Occupation Using Computers
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