AcuSpace Health Clinc New Patient Health Evaluation Form

AcuSpace Health Clinic New Patient Health Evaluation Form

The following questionaire is a comprehensive look at your health. It will take about 5 minutes to complete
Full Name

First NameLast Name
GENERAL INFORMATION
Date of Birth

MonthDayYear
Height if known
Weight if known
What are the main reasons you are seeking health care?*

Allergy, Cough, Sinus IssuePain management, HeadacheMenopause SymptomsPre-conception & Pregnancy CareStress, Depression, Anxiety, InsomniaDigestive Support, Thyroid Issue, MetabolismEnergy & DetoxCardiovascular ProtectionOther
How do you rate your pain level if you chose pain management? (0 = no pain, 10 = unbearable)*
The following questions: 1 - 10 (1=poor / 10=excellent)
How do you rate your current level of health*
How do you rate your current level of energy or vitality*
How do you rate your current stress levels*
How many hours sleep do you get a night?*
Do you have trouble getting to sleep?*
Do you wake often, or get woken easily?*
Do you have to go to the bathroom during the night?*
Do you snore or have breathing problems during sleep?*
Do you have known allergies?*
Please list any known allergies*
Please list any medications you are currently taking (e.g. warfarin, contraceptives, laxatives)
Please list any supplements you are currently taking
For Women ...

GYNECOLOGICAL HISTORY

Menstrual Info

	Please specify
Date your last period started
Date the period before that started
Age when your periods first beganAge when your periods first began
How often do you get your period? (days)
How long do your periods last? (days)
Number pads/tampons you use on heaviest days

	bright red	normal red	dark red	faint red	brown
Blood flow color

	Yes	No
Any abnormal vaginal discharge
Any heavy flow, severe cramps, or skipped periods
Any clots in the flow?
Any spotting or bleeding between periods
Do you use scented feminine products?
Do you use douches?
Have you ever had a gyn exam?

Are there any of the following medical conditions in your family history that you are aware of? Please tick all that apply.

ArthritisAsthmaAutoimmune Disorders (e.g. lupus, rheumatoid arthritis)Bowel DisordersCancerDementia / AlzeihmersDepressionDiabetesHeart AttackHigh Blood PressureHigh CholesterolLow Blood PressureMental IllnessMuscular DystrophyObesityOsteoporosisOsteoporosisSkin DisordersStrokesThyroid Over ActiveThyroid Under ActiveOther
Additional info you might want to share
Next: Diet and lifestyle . .
Do you exercise?*

Never1-2 times a week3-4 times a week5-6 times a weekEveryday
Please list the types of exercise you do regularly
Do you smoke?*
How many per wk?
Do you take recreational drugs?
Please list any food allergies / intolerances that you are aware of?
How many glasses of water do you have a day?*
Do you drink alcohol?

YesNo
How many per week?*
Vegetarian or vegen:*
Age >50 years:*
Planning to have a baby in the next 3-6 months:*
Pregnant or breastfeeding:*
Do you diet often?:*
Are you unhappy with your weight?:*
Should be Empty:

AcuSpace Health Clinic New Patient Health Evaluation Form