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:
Please clarify above responses, as needed:
GENERAL SYMPTOMS:
Please clarify above responses, as needed:
HEAD, EYES, EARS, NOSE, THROAT
Please clarify above responses, as needed:
RESPIRATORY
Please clarify above responses, as needed:
CARDIOVASCULAR AND CIRCULATORY
Please clarify above responses, as needed:
GASTROINTESTINAL
Please clarify above responses, as needed:
MUSCULOSKELTAL
Please clarify above responses, as needed:
SKIN AND HAIR
Please clarify above responses, as needed:
NEUROPSYCHOLOGICAL
Please clarify above responses, as needed:
GENITOURINARY
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?
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
Alcohol Consumption
Dietary Preferences:
Other dietary restrictions:
Caffeine Consumption (ex. coffee, tea, pre-workout drinks)
Do you smoke?
History of Recreational Drug Use?
Please clarify any responses above, as needed:
Water Consumption
Do you drink any of the following regularly?
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: