Health History and Medications FCM Part 2

Health History and Medications

Part 2 of 2
Thank you for filling out Part 1 of the Health History and Medication form for Functional Chinese Medicine!

Please continue filling out Part 2 below and your Health History and Medication forms will be completed!
Todays Date

MonthDayYear
Date
Name
Phone
Email
example@example.com

	Please indicate how many you've had/have:
Pregnancies:
Miscarriages:
Abortions:
Living children:
Vaginal deliveries:
Cesarean:
Term births:
Premature births:

Menstrual History (if currently menopausal, answer to the best of your recollection)

Menstrual Flow (please indicate which days you have the following flow)

	Which day of your period (e.g. Day 1, Day 3-4)
Light/spotting on days:
Medium on days:
Heavy on days:
With clots on days:
Spotting between periods on days:
Spotting before period on days:

Menstrual Color (please indicate which days you have the following colors of blood)

	Which day of your period (e.g. Day 1, Day 3-4)
Light red on days:
Bright red on days:
Dark red on days:
Purple on days:
Brown on days:
Black on days:

Lifestyle Review: Sleep
Bedtime on weekdays (workdays):
Wake time on weekdays (workdays):
How many hours of sleep is ideal for you?
How much sleep do you get?
How long could you sleep if you were allowed to sleep?

<7 hours7-8 hours9-10 hours10+ hours
Do you nap during the day?

YesNoI would if I had timeI'm not a napper
What is your bedtime routine?

Current Exercise Program:

Do you feel motivated to exercise?

YesA littleNo
Are there any problems that limit exercise?

YesNoOther
Do you feel unusually fatigued or sore after exercise or need long recovery time?

YesNo
If yes, please explain:

	Servings
Fruit
Vegetables (not including white potatoes
Red Meat
Chicken/turkey
Nuts & Seeds
Fish
Avocados & Oils
Legumes (beans, peas, etc)
Dairy
Junk food (chips, popcorn, candy, cookies, cake, soda, ice cream, etc.)
Bread/potatoes/pasta

	Check all that apply
Monosodium glutamate (MSG)
Artificial sweeteners
Garlic/onion
Cheese
Citrus foods
Chocolate
Alcohol
Red wine
Preservatives
Food colorings
Sulfite-containing foods (wine, dried fruit salad bars)

	Check the box if the factor applies to you
Fast eater
Eat too much
Late-night eating
Super hungry at dinnertime
Afternoon slump and grab something to eat
Eat to stay awake during the day
Dislike healthy foods
Time constraints
Travel frequently
Eat more than 50% of meals away from home
Don't care to cook
Confused about nutrition advice
Healthy foods not readily available
Too much junk food
Significant other or family members don't like healthy foods

	Check the box if the factor applies to you
Significant other or family members have special dietary needs
Love to eat
Eat because I have to
Have negative relationship to food
Struggle with eating issues
Emotional eater (eat when sad, lonely
Eat too much under stress
Eat too little under stress
Eat well all day and then blow it at night
Eat well during the week and less rigid on the weekends
No matter how much I exercise and how little I eat I don't lose weight
No matter how much I eat I don't gain weight

	Rate on scale of 1-10 (10 being the highest)
Work
Family
Social
Finances
Health
Other

	Yes	Severe
Low sexual energy
High sexual energy
Vaginal dryness
Vaginal discharge
Frequent yeast infections
Uterine prolapse
Bladder prolapse
Pelvic adhesions
Vaginal pain
Endometriosis
Infertility
Fibroids
Ovarian cysts
Pelvic inflammatory disease
STD
Fibrocystic breasts
Mastitis

	Mother	Father	Brother	Brother	Sister	Sister	Child	Child	Child	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal Grandfather	Other
Age (if still alive)
Age at death (if deceased)

Health History and Medications

	1	2-4 cups	>4
Coffee (cups per day)
Tea (cups per day)
Caffeinated sodas-regular or diet (cans per day)

	5	4	3	2	1
Significantly modify your diet
Take several nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (e.g., work demands, sleep habits)
Practice a relaxation technique
Engage in regular exercise