• 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!

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  • Format: (000) 000-0000.

  • Women's History

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  • 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?
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  • Gynecological & PMS Symptoms

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

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

  • Family History

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  • Dental History

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  • 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

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  • 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?
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  • Do you drink caffeinated beverages?
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  • Do you have any adverse reactions to caffeine?

  • Nutrition

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  • Do you have any sensitivities to certain foods?
  • Do you have an aversion to certain foods?
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  • Are there any foods that you crave or binge on?
  • How many meals do you eat out per week?
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  • 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?
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  • 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

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  • Readiness Assessment

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  •  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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