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Have you had acupuncture before?
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How long have you had this condition?
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What seems to make it better?
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Your Past Medical History
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AIDS/HIV
Emphysema
Pacemaker
Tuberculosis
Alcoholism
Epilepsy
Pleurisy
Typhoid Fever
Allergies
Goiter
Pneumonia
Ulcers
Appendicitis
Gout
Polio
Venereal Disease
Arteriosclerosis
Heart Disease
Rheumatic Fever
Thyroid Disorders
Whooping Cough
Asthma
Hepatitis
Scarlet Fever
Major Trauma
Cancer
Measles
Seizures
Chicken Pox
Multiple Sclerosis
Stroke
Diabetes
Mumps
Surgery: List
Other: Specify
Dietary Restrictions or Allergies?
Recent Western Medical Tests
Cholesterol value
Prostate / PSA value
Blood tests — please list
Other tests — please list
Pharmaceuticals Used
Your Lifestyle
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Alcohol
Marijuana
Stress
Tobacco
Drugs (recreational)
Occupational Hazard
Regular Exercise?
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No
Exercise Type
General Symptoms
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Poor Appetite
Poor Sleep
Cold Hand/Feet
Night Sweats
Peculiar Taste
Heavy Appetite
Too Heavy Sleep
Poor Circulation
Sweat Easily
Strongly like Cold Drinks
Dream disturbed sleep
Shortness of Breath
Muscle Cramps
Strongly like Hot Drinks
Fatigue
Feverish Feeling
Vertigo or Dizziness
Recent Weight Gain/Loss
Body Heaviness
Chills
Bruise or bleed easily
Head, Eyes, Ears, Nose, Throat Symptoms
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Eye Strain
Night Blindness
Sores on Lips or Tongue
Recurrent Sore Throat
Headaches
Eye Pain
Glaucoma
Dry Mouth
Swollen Glands
Migraines
Red Eyes
Cataracts
Excessive Saliva/Drool
Lumps in Throat
Concussion(s)
Itchy Eyes
Teeth Problems
Sinus Problems
Enlarged Thyroid
Spots in Eyes
Grinding Teeth
Excessive Phlegm
Nose Bleeds
Poor Vision
TMJ
Ringing in Ears
Blurred Vision
Facial Pain
Gum Problems
Poor Hearing
Earaches
Color of Phlegm (HEENT)
Other Head or Neck Issues
Respiratory Symptoms
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Difficulty Breathing Lying Down
Shortness of Breath
Tight Chest
Asthma/Wheezing
Cough
Coughing Blood
Pneumonia
Cough: Wet or Dry?
Cough: Thick or Thin?
Color of Phlegm (Respiratory)
Cardiovascular Symptoms
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High Blood Pressure
Low Blood Pressure
Chest Pain
Tachycardia
Phlebitis
Blood Clots
Fainting
Difficulty Breathing
Heart Palpitations
Irregular Heartbeats
Gastrointestinal Symptoms
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Nausea
Diarrhea
Intestinal Pain or Cramping
Vomiting
Constipation
Itchy Anus
Acid Regurgitation
Laxative Use
Burning Anus
Gas
Black Stools
Rectal Pain
Hiccup
Bloody Stools
Hemorrhoid
Bloating
Mucous in Stools
Anal Fissure
Bad Breath
Bowel Movements: Frequency
Bowel Movements: Color
Bowel Movements: Consistency
Bowel Movements: Odor
Musculoskeletal Symptoms
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Neck/Shoulder Pain
Upper Back Pain
Joint Pain
Limited Range of Motion
Muscle Pain
Low Back Pain
Rib Pain
Weakness in Muscle
Other musculoskeletal (describe)
Skin and Hair Symptoms
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Rashes
Eczema
Dandruff
Changes in Skin/Hair Texture
Hives
Psoriasis
Itching
Fungal Infection
Ulcerations
Acne
Hair Loss
Other Hair or Skin Problems
Neuropsychological Symptoms
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Seizures
Poor Memory
Irritability
Considered/Attempted Suicide
Numbness
Depression
Easily Stressed
Seeing a Therapist
Tics
Anxiety
Other neuropsychological (specify)
Genito-Urinary Symptoms
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Pain on Urination
Blood in the Urine
Increased Libido
Impotence
Erection Problems
Frequent Urination
Unable to Hold Urine
Decreased Libido
Premature Ejaculation
Nocturnal Emission
Urgent Urination
Bedwetting
Incomplete Urination
Wake to Urinate
Kidney Stone(s)
Gynecological Symptoms
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Irregular Periods
PMS
Clots
Vaginal Discharge
Vaginal Sores
Breast Lumps
Age Menses Began
Duration of Flow
Length of Cycle (Day 1 to Day 1)
Vaginal Discharge Color/Amount
Age of Menopause
Number of Pregnancies
Number of Live Births
Premature Births
Date of Last PAP
Date Last Period Began
Other Important or Relevant Information
Other Important or Relevant Symptoms
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