|
Chief Complaint - (When did the problem begin? Suddenly/gradually?)
|
Describe the quality (e.g., sharp, dull, hot, cold, numbness, etc.) and frequency of your complaint.
|
|
Other Complaint(s)
|
What makes your condition feel better?
|
|
What makes your condition feel worse?
|
How does this problem affect your daily activities?
|
|
List the names of healthcare providers seen for this condition. Include diagnoses, treatments, and any changes to your condition
|
|
|
Other relevant history related to your condition.
|
List all prescriptions/supplements.
|
|
Have you had acupuncture? When/what conditions?
|
Rate your pain on a scale (currently).
|
|
Mark painful / distress areas with an "X" for pain, ("Z" for numbness)
|
|
|
Past Medical History (Include dates of onset)
|
|
|
Cancer
|
Date of Onset
|
|
Diabetes
|
Date of Onset
|
|
Hepatitis
|
Date of Onset
|
|
HIV
|
Date of Onset
|
|
Thyroid Disease
|
Date of Onset
|
|
High Blood Pressure
|
Date of Onset
|
|
Heart Disease
|
Date of Onset
|
|
Seizures
|
Date of Onset
|
|
Food intolerance or allergies
|
Hospitalizations/Surgeries/Significant Injuries (include dates)
|
|
Major scars (from accidents or surgeries)
|
|
|
Lifestyle
|
|
|
Exercise (include frequency and duration)
|
Sleep (hours per night)
|
|
Typical Daily Diet
|
Water Intake per day (cups)
|
|
Do you / have you consumed any of the following?
|
|
|
Tobacco
|
Type? How much? How often? For how long (years)?
|
|
Caffeine
|
Type? How much? How often? For how long (years)?
|
|
Alcohol
|
How much? How often? For how long (years)?
|
|
Other substances
|
Type? How much? How often? For how long (years)?
|
|
Treatments or health practices (psychotherapy, massage, yoga etc.)
|
|
|
Occupation
|
Occupational stress factors (physical, psychological, chemical)
|
|
Personal stress factors
|
|
|
Mother
• • •
|
Father
• • •
|
|
Sibling
• • •
|
Other family information
|
|
General
• • •
|
Sudden energy drop (time of day)
|
|
Head, Eyes, Ears, Nose, Throat
|
|
|
Headaches (type, location, frequency)
|
Sinus Problems
|
|
Pain
• • •
|
Corrective Lenses
|
|
Problems with vision
|
Problems with hearing
|
|
Teeth problems
|
Teeth grinding
|
|
Thyroid problems
|
Recurrent sore throat
|
|
Other head or neck problems
|
|
|
Neurological
• • •
|
Other neurological problems
|
|
Cardiovascular
• • •
|
Other cardiovascular problems
|
|
Respiratory
• • •
|
Other respiratory problems
|
|
Digestive
• • •
|
Other digestive problems
|
|
Genitourinary
• • •
|
Other genitourinary problems
|
|
Gynecologic
|
Age at first menses
|
|
Age at menopause
|
Menstrual information
• • •
|
|
Pregnant (mos.)
|
Pregnancies (#)
|
|
Other pregnancy information
• • •
|
Other gynecological problems
|
|
Mental-Emotional
• • •
|
Other mental-emotional problems?
|
|
Have you ever been treated for emotional problems?
|
Have you ever considered or attempted suicide?
|
