|
How did you hear about us?
|
|
|
Have you had acupuncture before?
|
Chinese herbal medicine before?
|
|
Reason for today’s visit
|
Any diagnosis given?
|
|
Have you had it in past?
|
How long have you had this
|
|
Is your condition getting
|
Level of pain
|
|
Is the problem aggravated by
• • •
|
If yes,describe when
|
|
Is the problem helped by
• • •
|
Diagnosing physician
|
|
Other Physicians treating you?
|
Date of last physical exam
|
|
Being treated for other problems
|
If yes,List problem
|
|
Are you treated by other practit
|
PreviousTreatments
|
|
LIst your medications
|
Reason for medication
|
|
List any herbs you are taking
|
List supplements you are taking
|
|
Family medical history
• • •
|
List surgeries and date
|
|
Did you ever have/had
• • •
|
Accident/traumas with date
|
|
Inoculations you had
• • •
|
Inoculation had last year
|
|
Taken adrenal corticosteroids
|
More than 2 Course of antibiotic
|
|
Travelled outside country
|
Which countries?
|
|
Unusual birth history
|
|
|
Medical History
|
|
|
General Symptoms
• • •
|
Musculoskeletal
• • •
|
|
Eyes
• • •
|
Head, Ears, Nose, Mouth ,Throat
• • •
|
|
Cardiovascular
• • •
|
Cardiovascular Continued
• • •
|
|
Respiratory
• • •
|
Skin and Hair
• • •
|
|
Gastrointestinal
• • •
|
Frequency of Bowel Movements
|
|
Urinary and Genital
• • •
|
How often you urinate at night
|
|
Urinate in 24 hours
|
|
|
Sleep
• • •
|
Hours you sleep
|
|
Emotional
• • •
|
Treated for emotional Problems
|
|
Emotionally abused
|
Sexually abused
|
|
Unusual Stressful Experience
|
Physically abused
|
|
Other emotional problems
|
Any numb areas?
|
|
Pregnancy and Gynecology
• • •
|
|
|
Pregnancy/Gynecological Problem
|
Date of last menses
|
|
Date of last pap test
|
Method of birth control
|
|
Other
|
Other
|
