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