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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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How long have you had this?
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Have you had it in past?
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If yes,describe when:
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Other Physician(s) treating you?
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Current level of pain/discomfort:
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Being treated for other problems?
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Diagnosing physician:
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Being treated by anyone else?
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If yes, please list problem:
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LIst your medications:
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Previous Treatments:
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List any herbs you are taking:
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List surgeries and date:
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Family medical history:
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List supplements/vitamins you are taking:
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Have you ever had or do you now have?
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Accident/traumas with date:
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Travelled outside the country?
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Unusual birth history?
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Sleep:
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Which countries?
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Pregnancy and Gynecology
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Emotional
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Pregnancy/Gynecological Problem
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Date of last pap test
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Pacemaker?
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Hours you sleep
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New Field
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Method of birth control:
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Seizures?
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