Dr. Sharon Johnson-Eby, L.Ac., DCM An Medi-Zen LLC

Sex: male female trans other non-binary ( ) Pronouns: He/Him She/Her They/Them, or

Your primary doctor's contact information: Name

Please indicate any significant illness you or a blood relative have had:

Heart/Cardiovascular Disease Lung/Respiratory Disease Kidney Disease

Infectious Disease Tuberculosis

Health History Please list any medications and supplements you are currently taking: (Continue on back if necessary)

Please check if any of the following statements are true for you. have known allergies am taking anticoagulants have a pacemaker I am pregnant

Please indicate the use and frequency of the following:

How do you FEEL about the following areas of your life: Good Average Poor

What are the main health problems for which you are seeking treatment?

Please list any other health problems you now have:

Please list any allergies or food sensitivities you may have:

Please list any accidents, surgeries or hospitalizations (including date):

Please list any special considerations or circumstances you would like your practitioner to

Have you received acupuncture before? Yes No

Date of last prostate checkup PSA results

Color of urine: Clear Frequency of urination: Daytime Symptoms related to prostate: Delayed stream ( )Dribbling ( )Rectal dysfunction Increased libido Incontinence ( Decreased libido Testicular pain Retention of urine Premature ejaculation Back pain Other:

Age of first period (menarche) Age of last period (menopause) Number of days between periods Number of days of flow Number of pads/tampons on heaviest day Color of flow: Red Are you pregnant? yes no Number of pregnancies Number of abortions

Purple( Dark( Brown( Clots: yes( ) not )

Number of miscarriages, Date of last: Gynecological exam Pap smear Mammogram Have you been diagnosed with: Fibroids( ) Fibrocystic breasts Ovarian cysts Other ( Symptoms associated with menses: Pain Nature of pain: Cramping Stabbing Burning Intermittent Bearing down sensation Discharge Nature of discharge: Clear White Yellow Thick Thin Scanty Copious Headache Swollen breasts Mood swings Irritability Decreased libido Hot flashes Increased libido Nausea Diarrhea Constipation Vaginal Dryness Night sweats Ravenous appetite Poor appetite Insomnia Other: