Health History & Medications - Acupuncture

Menopause
Are you currently menopausal?

YesNo (if not, please skip the rest of this section)
In what year was your last period?
Do you currently experience any:

Night sweaterHot flashes (daytime)Vaginal drynessSpottingOther

Medications and Supplements
Name
DOB
Age
Please list all medications (prescription and over-the-counter) and vitamins, supplements, and herbs you are currently taking.
MEDICATIONS
Today's Date

MonthDayYear
Date

Please list all medications you are currently taking.

	Medications (Prescription & Over-the-Counter)	Dose	Frequency	Purpose	Approximate Date Started
1
2
3
4
5
6

Vitamins, Supplements, & Herbs

Please list all vitamins, supplements, and herbs you are currently taking.

	Vitamins, Supplements & Herbs	Dose	Frequency	Purpose	Approximate Date Started
1
2
3
4
5
6
7
8
9

Allergies:
Please list any known allergies to medications, foods, pollens, metals, etc.
Other:
Do you have a pacemaker?

YesNo
Do you have a bleeding disorder?

YesNo
Are you or could you be pregnant?

YesNo
Cancellation and Payment Policies

Payment is due on the day of the appointment. Receipts for insurance & healthcare/flex spending accounts reimbursements can be provided, please ask!

Please give us 24 hours advance notice if you need to cancel an appointment. You may be charged if you cancel an appointment without 24 hours notice.

Thank you for taking the time to fill out your health history so we can create the best treatment plan for you! We're looking forward to working with you!

Note: Please also fill out the Policies and Informed Consent form so your paperwork is complete!
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