Patient Medical History Form

Confidential Health History & Lifestyle Questionnaire
Today's Date

MonthDayYear
Patient Gender*
Patient Name*

First NameMiddle NameLast NameSuffix
Patient Birth Date*

MonthDayYear
Cell Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Patient E-Mail
Emergency Contact

Area CodePhone Number
Name and Relationship

First NameLast NameRelationship
Condition(s) for which you are seeking treatment:*
Is this your first acupuncture treatment?
How were you referred to us?
Name of the Person Who Referred You (if applicable):
Patient Medical History
Please list any food, drug, or herbal allergies*
Please check any of the following conditions that currently affect you, or have been significant to your health history:
GENERAL HEALTH HISTORY:

AllergiesAnemiaArthritisAsthmaAutoimmuneCancerDiabetesElevated CholesterolHepatitisHerpesHIV / AIDSHigh Blood PressureLow Blood PressureOsteoporosisReproductive IssuesSTDsSkin ConditionsThyroid DisordersTuberculosisUrinary IncontinenceThyroid ProblemsTuberculosis
Please clarify above responses, as needed:
GENERAL SYMPTOMS:

Poor AppetiteHeavy AppetiteStrong Preference for Cold DrinksStrong Preference for Hot DrinksPeculiar TasteCravingSweats EasilyNight SweatsPoor SleepDream Disturbed SleepUse CPAP MachineChillsFeverCold Hands or FeetPoor CirculationVertigo or DizzinessFatigueLack of StrengthShortness of BreathMuscle CrampsRestlessnessChronic Fatigue
Please clarify above responses, as needed:
HEAD, EYES, EARS, NOSE, THROAT

HeadachesMigrainesFacial PainGlassesPoor VisionBlurred VisionEye StrainItchy EyesDry EyesSpots in Visual FieldGlaucomaNight BlindnessSores on Lips or TongueSwollen GlandsDry MouthExcessive SalivaRecurrent Sore ThroatLumps in ThroatTMJ / Jaw PainTeeth ProblemsGrinding or Clenching TeethSinus ProblemsEnlarged ThyroidExcessive PhlegmEar Aches or Ear PressureRinging in EarsPoor Hearing
Please clarify above responses, as needed:
RESPIRATORY

Difficulty Breathing When Lying DownShortness of BreathTight ChestCoughPhlegm in LungsAsthma/WheezingPneumoniaValley Fever
Please clarify above responses, as needed:
CARDIOVASCULAR AND CIRCULATORY

High Blood PressureTightness in ChestBlood ClotsFaintingDifficulty BreathingHeart PalpitationsChest PainHistory of Heart AttackStroke or TIADizzinessRaynaud's DiseaseVaricose VeinsEdema
Please clarify above responses, as needed:
GASTROINTESTINAL

DiarrheaConstipationLoose StoolLaxative UseUrgency with Bowel MovementsMucus in StoolBlood in StoolItchy AnusAnal FissuresGasBloatingIntestinal Pain or CrampingBurning AnusHemorrhoidsNauseaVomitingAcid RefluxBad BreathHiccupUlcersIrritable Bowel SyndromeGallstonesCrohn's DiseaseUlcerative Colitis
Please clarify above responses, as needed:
MUSCULOSKELTAL

Neck PainShoulder PainUpper Back PainElbow PainArm PainLower Back PainRib PainSciatica PainHip PainGroin PainKnee PainMuscular PainLimited Range of MotionLimited UseFibromyalgiaMultiple MyalgiaSpasms/CrampsSprains/StrainsPostural DeviationsTendinitisWrist PainAtrophy/Difficulty Maintaining Muscle
Please clarify above responses, as needed:
SKIN AND HAIR

RashesEczemaPsoriasisDry SkinItchy SkinHivesFungal InfectionsAcneDandruffHair LossPremature Graying or Balding
Please clarify above responses, as needed:
NEUROPSYCHOLOGICAL

SeizuresPoor MemoryIrritabilityNumbnessDepressionAnxietyOCDTicsEmotional TraumaBipolar DisorderDifficulty ConcentratingConsidered or Attempted SuicideNumbness, Tingling, TwitchingALSMultiple SclerosisParkinson's DiseaseBell's PalsySpinal Cord InjuryTrigeminal Neuralgia
Please clarify above responses, as needed:
GENITOURINARY

Pain with UrinationBlood in UrineUrinary Dribbling/IncontinenceBurning with UrinationDifficulty UrinatingFrequent Bladder InfectionsBedwettingIncomplete UrinationKidney StoneKidney InfectionKidney DiseaseVenereal DiseaseLow LibidoYeast InfectionsErectile Dysfunction
Please clarify above responses, as needed:
Menstrual Cycle
Are you pregnant?
Do you menstruate?
What is the duration of your flow?
How is your overall flow?
How much clotting do you have during menstruation?
How are your menstrual cramps?
How long do your cramps last?
Do you have irregular bleeding outside your menstruation?
What symptoms do you experience premenstrually?

Mood swingsBreast tendernessHeadachesMigrainesDigestive UpsetFluid RetentionAnxietyDepressionFood Cravings
Is infertility a concern?
Other Health Issues:
Please note any current health issues, such as cold/flu, fever, infection or other contagious disease:
Please list any Surgeries and Dates of Each
Is there anything else not mentioned above that you feel is signficant?
Please list your current medications (with dosages) and supplements*
Health Habits
Exercise

Never1-2 days3-4 days5+ days
Alcohol Consumption

I don't drinkLess than one serving per week1-3 servings per week4-6 servings per weekDailyI consider it excessive
Dietary Preferences:

I eat meatI am vegetarianI am veganGluten freeDairy free
Other dietary restrictions:
Caffeine Consumption (ex. coffee, tea, pre-workout drinks)

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
History of Recreational Drug Use?

YesNoCurrently Use
Please clarify any responses above, as needed:
Water Consumption

NoneLess than 16 oz daily16-32 oz daily32-64 oz dailyGreater than 64 oz daily
Do you drink any of the following regularly?

CoffeeInstant teaHerbal teaFruit juiceVegetable juiceRegular sodaDiet soda
How do you feel about needles?*
Do you bleed or bruise easily?*
Please be advised that while the acupuncture needles are extremely small and normally do not elicit much, if any, bleeding that occasional bruising is a normal, although infrequent occurrence with acupuncture treatments. Please don't be alarmed if bruising does occur; however, you are welcome to notify your practitioner at any time if you have concerns. The body's tendency to bleed may be affected by taking blood thinners, baby aspirin, other medications, or by individual deficiencies.

PLEASE READ AND SIGN

I acknowledge that the above information is complete and accurate to the best of my knowledge. I agree to the release of information if necessary for insurance purposes. I clearly understand that acupuncture treatments are my personal financial responsibility, and I agree to pay for these services at the time of treatment unless prior arrangements have been made.

When I schedule an appointment for acupuncture, I understand that this time is reserved for me. In fairness to other patients, I agree to observe the 24-hour cancellation/rescheduling policy. If less than 24 hours notice is given, I understand I may be charged $25. Signing this form is an agreement to this policy.

I also agree that I have been presented with a copy of the "Notice of Privacy Practices" for Tempe Acupuncture Center, detailing how my information may be used and disclosed as permitted under federal and state law.
Please use your mouse or touch pad to sign below. *
Date Signed*

MonthDayYear
If signed by someone other than the patient, please indicate your name and relationship to the patient:
Should be Empty:

Confidential Health History & Lifestyle Questionnaire

Patient Medical History

Menstrual Cycle

Other Health Issues:

Health Habits