Personal Health History Form

Health History Form

HB Acupuncture
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City County

Post Code
Date of Birth: *

Day Month Year
Your Email Address: *
example@example.com
Your Mobile No. *

Area Code Phone Number
Your Occupation:
Your Primary Complaint Details: *
Primary Complaint Started

Day Month Year
Date
Your Secondary Complaint Details
Secondary Complaint Started

Day Month Year
Date
Current Medical Treatment: Please list any medical examination/investigations you have had e.g. Blood/Stool tests, ECG, Endoscopy, Scans and significant results?
Personal Health History
Fathers Health (Known Genetic issues if applicable)
Mothers Health (Known Genetic issues if applicable)
Current Medication: (if any) Please including HRT/birth control
Please list any Allergies you have:
Please list Accidents/ Injuries / Operations / Broken Bones / Hospitalisation:
Diseases - Please check the diseases you have had.
What is your weight (Imperial or Metric as your prefer)
What is your Height? (Feet or Metres)
What is your BMI (BMI = Weight/Height)
Please enter your BMI
Immunisation: Please check box if you have immunised.
Problems in Childhood.
Health Questions: (Please check each relevant condition).
If you smoke, please indicate for how long in years. Set "0" for non smoker
How many portions of vegetables do you consume daily?
How many portions of fresh fruit do you consume daily?
Do you eat meat?

Yes No
If you are a vegetarian, what is your protein source?
Please indicate
Do you eat dairy products?

Yes No
Do you eat sugary foods?

Yes No
Do you eat Grains/Pulses?

Yes No
WOMEN ONLY: Do you think you maybe pregnant?

Yes No
If you have stopped Menstruating, when was your last period (Approx)
Please advise the number of pregnancies you have had?
Mothers: Please comment on your experiences during pregnancy and labour. e.g. Back Pain, Epidural, Cesarean Section, High Blood Pressure etc.
Please provide all relevant details:
Your Doctors Name:
Please confirm your Doctors name:
Practice Name:
Please confirm the practice name:
Practice Address

Street Address

Street Address Line 2

City County

Post Code
Practice Telephone No.

Area Code Phone Number
To the best of my knowledge, all statements made in this case history are true.

Clear
If you are signing on behalf of a minor, please provide your full name and relationship to the patient.

Full Name Relationship
Please check "Yes" or "No" that you are happy to receive occasional newsletters, special offers or vouchers via email? Please note that your contact or health details will NOT be passed to any 3rd party.

Yes No
In order to SAVE and return to your form, you will be prompted to create a Jotform account. Otherwise, please just press Submit and your form will be sent directly to HB Acupuncture.
Please provide 24 hours advance notice if you need to cancel your appointment.

If less than 24 hours notice is given the full fee is charged.

No show appointments will be charged the full fee.
Cash or cheque only.

Please do check with your insurance company for the cover of acupuncture treatment.

Thank you for completing this form. Your Practitioner will ask you
for more details during the consultation.
Should be Empty:

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