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How did you find us?
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If you were referred, by whom?
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Have you had acupuncture before?
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When?
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By whom?
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Marital Status
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Number of Children
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Illnesses you've had:
• • •
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Illnesses of Immediate Family:
• • •
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Black tea/coffee
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How often?
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Cigarettes
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How many per day?
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Smokeless tobacco
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How often?
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Alcohol
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How often and how much?
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Non-medical drugs
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What and how often?
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Soda
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How much and how often?
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How much water do you drink?
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For what do you seek treatment?
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Which specialists do you see now
• • •
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List other health concerns
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List past surgeries
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List any hospitalizations
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Rate how you feel about each:
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Significant other
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Spirituality
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Exercise
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Diet
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Self
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Work
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Family
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Sex
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Anything special we need to know
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Symptom Survey
• • •
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For Women
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Age of first period
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Age of last period (menopause)
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Number of days between periods
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How many days of flow?
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Color of flow?
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Are there clots?
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Color of the clots?
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Average # of pads: Day 1
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Day 2
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Day 3
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Day 4
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Additional days
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Have you been diagnosed with:
• • •
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Any others?
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Do you have Pre-menstrual pain?
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Location of the pain
|
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When do you have pain?
• • •
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What does it feel like?
• • •
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Other symptoms of menstruation?
• • •
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Are you currently pregnant?
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# of pregnancies you've had
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# of live births
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# of abortions
|
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# of miscarriages
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Any additional comments?
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Date of last GYN exam
/
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Date of last Papsmear
/
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Date of last mammogram
/
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Date of last bone density scan
/
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For Men
|
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Date of last prostate exam
/
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Manual exam results
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PSA results
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# of times you urinate per day
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# of times you urinate at night
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Color of the urine
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Other qualities
• • •
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Other prostate symptoms?
• • •
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Others not mentioned?
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