• Health History and Medications

    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
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Women's History

  • Reproductive History
    Rows
  • Are you currently trying to conceive?
  • Are you currently lactating?
  • Past or present use of hormonal birth control?
  • Any problems with hormonal birth control?
  • Current use of other contraception?
  • Menstrual History (if currently menopausal, answer to the best of your recollection)
    Rows
  • Menstrual Flow (please indicate which days you have the following flow)
    Rows
  • Menstrual Color (please indicate which days you have the following colors of blood)
    Rows

  • Gynecological & PMS Symptoms

    Mark YES for mild or moderate symptoms you've had in the past 6 months. Mark SEVERE if a significant symptom.
  • Gynecological Symptoms
    Rows
  • PMS
    Rows

  • Menopause

  • Have you gone through menopause?
  • Was it surgical menopause?
  • Are you on hormone replacement therapy?
  • Current symptoms (check all that apply):

  • Family History

  • Ages
    Rows
  • Family Health History: Check family members that have/had any of the following:
    Rows

  • Dental History

  • Please type YES if you have had any of the following, and provide number if applicable:
    Rows
  • Did you have any mercury fillings removed?
  • Do you brush your teeth regularly?
  • Do you floss regularly
  • Dental issues:

  • Environmental/Detoxification History

  • Do any of these significantly affect you?
  • In your work or home environment are you regularly or recently exposed to: (check all thatapply
  • Have you had any significant exposure to any harmful chemicals?
  • Do you have any pets or farm animals?
  • If yes, do they live:
  • Do you feel worse in certain environments?

  • Smoking

  • Do you smoke currently?
  • What type?
  • Are you regularly exposed to second-hand smoke?

  • Alcohol

  • How many alcoholic beverages do you drink in a week? (1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits)
  • Previous alcohol intake?
  • Have you ever had a problem with alcohol?
  • Have you ever thought about getting help to control or reduce your drinking?

  • Other substances

  • Are you currently using any recreational drugs?
  • Have you ever used IV or inhaled recreational drugs?

  • Lifestyle Review: Sleep

  • How long could you sleep if you were allowed to sleep?
  • Do you nap during the day?

  • Exercise

  • Current Exercise Program:
    Rows
  • Do you feel motivated to exercise?
  • Are there any problems that limit exercise?
  • Do you feel unusually fatigued or sore after exercise or need long recovery time?

  • Diet

  • Do you eat 3 meals a day?
  • If you don't eat 3 meals a day, which meal(s) do you skip?
  • Are you hungry for breakfast?
  • Do you snack at night?
  • Please list what you eat in a typical day:
    Rows
  • How many SERVINGS do you eat in a typical WEEK of these foods:
    Rows
  • Do you drink caffeinated beverages?
  • If you drink caffeine, how much of it?
    Rows
  • Do you have any adverse reactions to caffeine?

  • Nutrition

  • Do you currently follow and of the following special diets or nutritional programs?
    Rows
  • Do you have any sensitivities to certain foods?
  • Do you have an aversion to certain foods?
  • Do you adversely react to:
    Rows
  • Are there any foods that you crave or binge on?
  • How many meals do you eat out per week?
  • Check the factors that apply to your current lifestyle and eating habits:
    Rows
  • Check the factors that apply to your current lifestyle and eating habits:
    Rows

  • Stress

  • Do you feel you have an excessive amount of stress in your life?
  • Do you feel like you can easily handle the stress in your life?
  • How much stress do each of the following cause on daily basis?
    Rows
  • Do you use relaxation techniques?
  • Which techniques do you use?
  • Have you ever sought counseling?
  • Are you currently in therapy?
  • Have you ever been abused, a victim of crime, or experienced a significant trauma?
  • Do you feel the trauma has been resolved?

  • Relationships

  • Marital status:
  • Do you have resources for emotional support?
  • Which are your resources for emotional support? (check all that apply)
  • Do you have a religious or spiritual practice?

  • Overall Lifestyle

  • How well have things been going for you? (Mark on scale 1-10, or n/a of not applicable)
    Rows

  • Readiness Assessment

  • Rate on a scale of 5 (Very Willing) to 1 (Not Willing): In order to improve your health, how willing are you to:
    Rows
  • Rate on a scale of 5 (Very Confident) to 1 (Not Confident At All):
    Rows
  • Rate on a scale of 5 (Very Supportive) to 1 (Very Unsupportive):
    Rows
  • Rate on a scale of 5 (Very Frequent Contact) to 1 (Very Little Contact):
    Rows

  •  Cancellation and Payment Policies

    Payment is due on the day of your appointment.

    We can provide receipts for insurance & healthcare/flex spending accounts reimbursements, please ask at your appointment!

     

    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 this questionnaire and educate us about your health history and lifestyle! With this information and your future visits, we'll partner together to help you achieve the most optimal health possible!

     

    As a final step, please fill out the Policies and Informed Consent on the New Patient Information page on our website after you hit 'Submit'.

     
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