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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

OnPatient Health History Info Medical Form

Acupuncture

Cara Frank OnPatient Health History Questionnaire

There are 514 copies in use.
Published: Dec. 12, 2012, 7:44 p.m.
Doctor: Dr. History Physical
Rating: +44   /

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328 Gibraltar Dr
Sunnyvale, CA 94089

Call us: (844) 569-8628

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