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