Health History Form

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Image Field
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Name* This field is required.
First Name
Last Name
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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What is your best email?* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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Health History (Confidential)We use a HIPPA certified software to ensure your Medical Privacy.
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Please answer the following questions:* This field is required.
What is your age?
Height:
Current Weight:
Biological Gender:
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Please check all that apply* This field is required.
I am Pregnant
Seizure Disorder
Pacemaker
Hemophilia
I take a Blood Thinner
Heart Disease
Emotional Disorder
Tuberculosis
High Blood Pressure
Herpes
HIV/AIDS
Cancer
Hepatitis
Diabetes
Tobacco
Alcohol
Marijuana
Other Drugs
NONE
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Please list all medications and supplements you take:* This field is required.Write none if currently not taking any.
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Do you have any:* This field is required.
Dietary Restrictions:
Allergies:
Food Senstivities:
Large Scars:
Skin Abnormalities:
Recurring Dreams:
Bad Habits:
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Do you have any food allergies?* This field is required.Are these true allergies or just sensitivies?
Huge
Large
Normal
Small
Ok
Ok
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Have you been diagnosed with Celiac Disease?* This field is required.
YESNO
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How does you body feel to you?* This field is required.
Dry
Damp
Hot
Cold
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Please describe how we can can help you?* This field is required.Be as specific as possible.
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Have you ever had acupuncture before?* This field is required.Including Dry Needling with a PT
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Who can we thank for referring you here?* This field is required.
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Please list your main complaints:* This field is required.On scale of 0-10, what is the intensity of each complaint?
Main complaint:
Additional complaint:
Additional complaint:
Additional complaint:
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How long has the main complaint been an issue?* This field is required.
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How do these health challenges affect your life?* This field is required.
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Have you had to give up anything you love because of this?* This field is required.
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How are you feeling about this?* This field is required.
Worried
Depressed
Angry
Overwhelmed
Frustrated
Exhausted
Afraid
Anxious
Lonely
Other
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How motivated are you to resolve this?* This field is required.
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Please tell us what you have tried to solve your health problem in the past?* This field is required.List all therapies, modalities, supplements, etc
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What are the main challenges to healing right now?* This field is required.What is blocking you from getting better?
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Are you willing to modify your diet to get better?* This field is required.
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Are you willing to adopt new habits?* This field is required.
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Do you have any upcoming medical procedures or changes in medications coming up?* This field is required.
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Which of these symptoms do you regularly experience?* This field is required.
Fatigue/exhaustion
Brain Fog
Digestive Issues
Dizziness (with standing)
Weak feeling/Lack of strength
Easy bruising
Carb/Sugar/Sweet cravings
Sticky Bowels
Loose/unformed Bowels
Hard/Dry Bowels
Dry Mouth + Always Thirsty
Dry Mouth + Rarely Thirstyd
Crave liquids (large gulps)
Little thirst (small sips)
Cloudy/Dark Urination
Phlegm/Mucus (nose, chest)
Poor night vision
Cramping/Twitching
Dizziness
Poor memory/forgetfullness
Low back/Leg/Knees cold/sore
Frequent Urination
Wake at Night to urinate
Cold feet/Toes (constant)
Low Libido/Interest in Sex
Ringing in ears/Difficulty Hearing
Pale nails, brittle nails, ridge lines
Varicose veins/Spider veins
Cherry Hemangioma
Fixed, Sharp, Stabbing Pain
Sigh often/Feels good to Sigh
Red, Inflamed Skin Conditions
Anger, Irritability, Fidgeting
None
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Tell us about your Menstrual Cycle (if applicable):Please be as specific as possible.
Cycle Length:
Menses, # of days:
Pain, where, when + intensity:
Any clotting? What is the quality? color, shape, texture
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Please let us know if there is anything we should be aware of, or that hasnt been covered yet.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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Disclosure, Consent + Privacy PracticesPlease read the form thoroughly before signing.
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I understand that full payment is expected at the time of service, unless prior arrange-ments have been made. Payment may be in the form of cash, check, or card (creditcards are subject to a 3% fee). The fee for returned checks is $40SIGN HERE:
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I agree to provide at least 24 hours notice by telephone in the event that I need to reschedule or cancel an appointment. I understand that the time is set aside for me, and that if I fail to provide 24 hours notice that I am accountable for the cost of the session.SIGN HERE:
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Herbs and other consumable products are non-refundable (even if “unused’ or”unopened”). In the event of a partial service package refund, all used sessions will be deducted from the total paid at the regular, pay-as-you-go, full rate. All refunds will be provided in the original form of payment within 2 weeks of request. All unused sessions expire after 1 year from the purchase date and will not be refunded after that point. Any refund requests must be made prior to the 1 year expiration date.SIGN HERE:
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Whidbey Acupuncture + Herbs is happy to provide itemized, medically coded superbills for insurance/HSA reimbursement purposes, as well as detailed, itemized receipts for tax purposes or other records. Please allow 2-4 weeks.SIGN HERE:
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Privacy Policy:By voluntarily signing below, I show that I have read or have had read to me, the Notice of Privacy Practices, and have had an opportunity to ask any questions.
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Disclosure & Consent:By voluntarily signing below, I show that I have read or have had read to me, the Disclosure & Consent to Chinese Medical Treatment and Care, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask any questions. By signing below, I consent to the treatment plan. I intend this consent to cover the entire course of my treatment, regardless of which condition is being primarily addressed.
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