Acupuncture Health History Form

Patient Information
Name _______________________________________________ Date________________________
Address _________________________________________________________________________
City____________________________ State________________________ Zip________________
Home Phone______________________________ Cell Phone_______________________________
Height_______ Weight_______ Sex: Male Female Marital Status___________________
Date of Birth_______________________ Age____________________________________________
Occupation________________________ Employer_______________________________________
Have you had acupuncture before? No Yes, Name of Acupuncturist_____________________
Major Complaint
Primary reason for your visit today?____________________________________________________
________________________________________________________________________________
Has this condition been diagnosed by a physician, or other provider? No Yes,
Diagnoses____________________________________________________________
Are you being treated for this condition by anyone else? Yes No
If yes, what is the treatment?_________________________________________________________
Have these treatments helped? Yes Somewhat Not Much Not At All
How does this condition affect you?____________________________________________________
How long have you had this condition?__________________________________________________
Personal Health History
Your general health as a child was? Excellent Good Average Poor
Did you feel safe and nurtured as a child? Always Usually Sometimes Never
Check all the illnesses or conditions which you currently have or have had in the past:
AIDs / HIV----- Eating Disorders ---- Kidney Disease ---- Rheumatic Fever -----
Alcoholism ----- Epilepsy ---- Measles------- Scarlet Fever------
Allergies------- Glaucoma------ Meningitis ----- Sexually Transmitted -----
Antibiotic Use ----- Heart Disease------- Mental Illness Disease -------
Asthma ------ Hepatitis------ Multiple Sclerosis----- Stroke ------
Bleed Easily ----- High Blood Pressure ------- Mumps------ Tuberculosis ------
Cancer ------- High Fevers -------- Obesity ------- Typhoid Fever -------
Chicken Pox ----- Hyperthyroid ------- Pneumonia -------- Ulcers -------
Diabetes -------- Hypothyroid --------- Polio ------- Vascular Disease-------
Drug Abuse------, Jaundice -------, Other____________________________________
Are you taking Coumadin or Warfarin? ------- Yes ------ No
Do you have a pacemaker? Yes-------, No-------, Do you have seizures? Yes -----, No ----
Do you currently have any infectious diseases? Yes -----, No----- Possibly
If yes, please identify: HIV / AIDs-------, Hepatitis B -----, Hepatitis C--- Flu / Cold ----- Streptococcus -------
Mononucleosis------ Tuberculosis------ Other____________________________________________
Known or suspected allergies:________________________________________________________
Personal Health Inventory
Please put a check mark ( 4 )by the symptoms that you have now. Place a star ( k ) next to the ones you
have noticed within the last three months.
Qi, Blood, Yin, Yang
anxiety loose stools you anger easily
catches colds easilyor frequently low appetite you feel better after exercise
chest pain traveling to shoulder mental heaviness, sluggishness or KI / BL
cold feet fogginess frequent urination
cold hands nausea hair loss
difficult to concentrate prolapsed organs (previously joint pain
dizziness diagnosed) lack of bladder control
dream disturbed sleep swollen feet loose teeth
dry skin swollen hands low back pain
fatigue you bruise easily memory problems
feverish in the afternoon or flushes ST night blindness or low vision
general weakness bad breath ringing in your ears
heat sensations in hands, feet, chest belching sore, cold or weak knees
insomnia bleeding, swollen or painful you get up more than one time at
mental confusion gums night to urinate
night sweats burning sensation after eating Other ______________________
palpitations constipation ___________________________
restlessness heartburn ___________________________
sores on tip of tongue large appetite ___________________________
speech problems mouth sores (canker or cold ___________________________
sweats easily sores) ___________________________O
thirst, at night stomach pain SU Student Health History Form • Updated
you feel worse after exercise vomiting 3/6/13 • Page 3
you see floating black spots HT / PC
LU chest pain
allergies edema
chills alternating with fever high blood pressure
cough insomnia low blood pressure
difficulty breathing palpitations stroke varicose
dry mouth, throat, nose veins
feeling achy LR / GB
headaches bitter taste in mouth
nasal discharge blood shot eyes
nose bleeds blurred vision
shortness of breath chest pain
sinus congestion convulsions
sneezing diarrhea alternating with
sore throat constipation
stiff neck/ shoulders difficulty swallowing
SP dry eyes
abdominal bloating and / or gas feeling of a lump in your throat
after eating headache at the top of your head
belching hot flashes
chest congestion muscle spasms, twitching,
constipation cramping
diarrhea numbness of hands and feet
eating disorders pain in rib cage
fatigue after eating red, sore or irritated eyes
gas seizures
general feeling of heaviness in skin rashes
your body tight feeling in chest
hemorrhoids TMJ or locked jaw
Family History
How do you feel about the following areas of your life in the past month.
Significant Other-----, Great ----, Good -----, Fair-----, Poor ----- N/A
Comments__________________
Family ------, Great------, Good-------, Fair------, Poor------,
N/A-----.Comments__________________
Self ----, Great ------, Good-----, Fair -----, Poor Comments__________________
Check illnesses which have occurred in any of your blood relatives:
Alcoholism----, Cancer-----, -- Heart Disease------, Mental Illness-------,
Allergies------, Diabetes ------, High Blood Pressure-----, Obesity------,
Bleed Easily-------,Epilepsy-----, Kidney Disease-----, Stroke-------.

Other__________________________________________________________________
________
Women Only
Are you pregnant? ----- Yes, How many months?____________________ No----, Trying
Maybe------
Method of birth control?
______________________________________________________________
Age of First Menses_________Date of Last Menses____________Age of
Menopause_____________
Typical Length of Menses (Days You
Bleed)______________________________________________
Typical Length of Cycle (From the 1st Day of One Cycle to 1st Day of the
Next)__________________
Number of:
Pregnancies________Births________Abortions________Miscarriages______________
Hysterectomy ------, Yes-----, Partial-------, Complete-------.
Date________________________________ No
Check all that apply to you:
Scanty Flow-----, Painful Periods-----, Low Libido----,
Heavy Flow-----, Breast Tenderness -------, Excessive Libido------,
Clotting -------, Breast Lumps --------, Painful Intercourse----,
Vaginal Discharge-------, Nipple Discharge-----, Infertility
Abnormal Pap Smear ------, Fibrocystic Breasts -----, Fibroids----,
Menopausal Symptoms -----,Bleeding Between Cycles----, Endometriosis------,
Premenstrual Problems ------, Irregular Cycles ------, Ovarian Cysts------.
Other__________________________________________________________________
________
Men Only
Check all that apply to you:
Low Libido-----, Seminal Emissions-----, Prostate Problems------,
Excessive Libido-------, Premature Ejaculation ------- Testicular Pain------,
Impotence -------, Painful Intercourse-----, Testicular Redness-------
Vasectomy, Date______________________________________________ Testicular
Swelling
Other__________________________________________________________________________

Medications Please list medications, herbal supplements and vitamins you are currently
taking:
Drug / Supplement / Vitamin Reason For Taking For How Long Dosage Frequency
______________________________________________________________________
___________
______________________________________________________________________
___________
______________________________________________________________________
___________
______________________________________________________________________
___________
______________________________________________________________________
___________
______________________________________________________________________
___________
Lifestyle
How would you rate the following areas of your health in the past month.
Digestion Great-----, Good ------, Fair------, Poor------,
Comments______________________________
Stools -----, Great----, Good-----, Fair ------, Poor-----.
Comments______________________________
How many times per day?__________________
Do they feel complete? Yes-----, No------,
Stool consistency? Loose -------, Formed ------,
Hard to Pass---- Other_______________
What is the colour of your stools?
_____________________________________________
Is there blood in your stools? Yes----, No-----, How Often?________________________
Urination Great-----, Good------, Fair----, Poor----.
Comments______________________________ How many times per day?
_____________What color is your urine?________________ After you've gone to sleep
do you get up to urinate? Yes-----, No -----, How Often?________________ Is your
urination painful? Yes-----, No-----.
Appetite Great-----, Good---- Fair----, Poor------
Comments______________________________
Diet Great----, Good-----, Fair-----, Poor------
Comments______________________________
re you vegetarian or vegan? Yes-----, No----, For how long?______________________
Food / Drink:
Foods You Crave_____________________________When?
_________________________________
Daily Water Intake____________________________Daily Soda Intake_____Caffeine?
Yes ----, No----. Daily Coffee Intake______Caffeine? Yes---, No----__,Daily Tea
Intake______Caffeine? Yes----, No----.
Do you drink alcohol? How Much?__________How Often?_____________What kinds?
_______________________________________Past Use? Yes----, No----
Date Stopped_________
Do you use tobacco? Yes -----, No-----, Past Use? Yes-----, No-----,
Date Stopped_________
Do you use recreational drugs? Yes----, No----, Past Use? Yes-----, No----- ,
Date Stopped_________
How do you feel about the following areas of your life in the past month.
Energy ------, Great------, Good------, Fair------, Poor-------.
Comments________________________________ On a scale of 1 to 10? (10 is high
energy)_______________________________________
Sleep ------, Great------, Good ------, Fair -------, Poor--------.
Comments________________________________ Hours per night?
_________________Do you wake feeling rested? Yes-----, No------
Sex Life ------, Great------ ,Good----, Fair------, Poor------.
Comments________________________________
Exercise------, Great------, Good ------, Fair ------, Poor------.
Comments________________________________ How often?
___________________________What kind?__________________________How
would you rate your stress level on a scale of 1 to 10? (10 is high stress)
_________________
How well do you feel you handle your stress? ------, Great-------, Good ------, Fair-----, Poor------.

Pain
Please answer the following questions if you have pain.
Indicate on the diagram your areas of pain
How long have you had this pain?___________________________________________
Describe the onset of your pain?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
___________________________________
On a scale of 1-10 (10 being worst) how strong is your pain?____________________
What does your pain feel like? (check all that apply)6 Dull 6 Sharp 6 Stabbing 6 Sore 6
Achy 6 Cramping 6 Burning 6 Constant 6 Comes and Goes 6 Fixed 6 Moves About
Does the pain radiate? 6 No 6 Yes Where?
__________________________________________
What helps the pain? 6 Ice 6 Heat 6 Rest 6 Movement 6 Pressure 6 Moisture 6 Massage
6 Nothing 6 Other_____________________________________________________
What aggravates the pain? 6 Ice 6 Heat 6 Rest 6 Movement 6 Pressure 6 Moisture 6
Massage 6 Nothing 6
Other_____________________________________________________
Does anything relieve this pain? (i.e.; medications, over the counter drugs,
liniments)______________________________________________________________
__________________
Other treatments you have had for this pain?
______________________________________________________________________
_______________________________________________________
Anything you wish to add?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_________
The above information is true to the best of my knowledge.

X Patient's Signature_______________________________________Date__