Sunriseacupuncture.com
Welcome
To help me provide you with a complete evaluation, please fill out this questionnaire thoroughly. Your answers will be kept confidential.
Health History
DATE: ________________________ EMAIL ADDRESS: _____________________________
NAME: ______________________________ DATE OF BIRTH: _______________ AGE: ________
ADDRESS: __________________________ HEIGHT: ____________ WEIGHT: _____________
____________________________________ GENDER: __ F __ M MARITAL STATUS: ________
PHONE (H): ________________ PHONE (C): _________________ PHONE (W): ________________
PHYSICIAN: _____________________________ REFERRED BY: ____________________________
EMERGENCY CONTACT: __________________ RELATION: ___________ PHONE: _____________
OCCUPATION: ___________________________ EMPLOYER: _______________________________
INSURANCE COMPANY: _______________________ POLICY #: _____________________________
Have you been treated by acupuncture before? □Yes □No Chinese herbs: □Yes □No
Reason for visit: ______________________________________________________________________
How long have you had this condition? ____________________________________________________
To what extent does this condition interfere with your daily activities? _____________________________
____________________________________________________________________________________
Western medical diagnosis: _____________________________________________________________
Treatment(s) that you have tried: _________________________________________________________
|Current Medications, Herbs, Vitamins |Dose per day |Duration |Reason |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
Allergies (drugs, food, environmental): _____________________________________________________
List all major surgeries, accidents, and traumas: _____________________________________________
____________________________________________________________________________________
Past Medical History (Please check all that apply)
|□ Asthma |□ Bleeding Disorders |□ Blood Pressure (High/Low) |
|□ Cancer |□ Diabetes |□ Hepatitis |
|□ HIV/AIDS |□ Heart Disease |□ Rheumatic Fever |
|□Seizures |□ Thyroid Disease (High/Low) |□Venereal Disease |
□ Other (Specify): __________________________________________________________________
Family History (Please check all that apply)
|□ Asthma |□ Allergies |□ Cancer |
|□ Diabetes |□ Heart Disease |□ High Blood Pressure |
|□ Stroke |□ Seizures |□ Thyroid |
□ Other (Specify): __________________________________________________________________
Please indicate any painful or distressed areas by circling them.
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Notes: _____________________________________________________________________________
___________________________________________________________________________________
Please check all that apply (in the last 3 months)
General
|□ Feeling hot |□ Peculiar tastes/smells |□ Poor Sleep |
|□ Sweat easily |□ Cravings |□ Fatigue |
|□ Night sweats |□ Change in appetite |□ Sudden energy drop |
|□ Bleed/Bruise easily |□ Weight loss |□ Strong thirst |
|□ Feeling cold |□ Weight gain |□ Thirst with no desire to drink |
Notes: ______________________________________________________________________________
Skin & Hair
|□ Rashes |□ Ulcerations |□ Hives/Allergic Dermatitis |
|□ Itching |□ Eczema/Psoriasis |□ Recent moles |
|□ Acne |□ Warts |□ Fungal infection |
|□ Change in hair/skin texture |□ Loss of hair |□ Dandruff |
Notes: ______________________________________________________________________________
Head, Eyes, Ears, Nose, and Throat
|□ Dizziness |□ Headaches |□ Migraines |
|□ Eye strain |□ Eye pain/itchiness |□ Blurred vision |
|□ Night blindness |□ Color blindness |□ Glasses |
|□ Spots in front of eyes |□ Cataracts |□ Poor hearing |
|□ Ringing in ears |□ Earache/Ear discharge |□ Sinus problems |
|□ Nose bleeds |□ Sores on lips/tongue |□ Facial pain |
|□ Grinding teeth |□ Jaw clicks/locks |□ Recurrent sore throats |
Notes: ______________________________________________________________________________
Cardiovascular
|□ Chest pain or pressure |□ Irregular heartbeat |□ Palpitation at rest |
|□ Fainting |□ Blood clots |□ Varicose/spider vein |
|□ High blood pressure |□ Low blood pressure |□ Shortness of breath |
|□ Perspiration without exertion |□ Swelling of hands/feet |□ Phlebitis |
Notes: ______________________________________________________________________________
Respiratory
|□ Asthma |□ Cough |□ Coughing blood |
|□ Bronchitis |□ Pneumonia |□ Production of phlegm |
|□ Difficulty breathing |□ Pain with deep inhalation |□ Wheezing |
Notes: ______________________________________________________________________________
Gastrointestinal
|□ Nausea |□ Vomiting |□ Bleeding gums |
|□ Bad breath |□ Gas |□ Belching |
|□ Diarrhea |□ Constipation |□ Blood in stools |
|□ Black stools |□ Indigestion |□ IBS/Crohn’s disease |
|□ Acid reflux/GERD |□ Hemorrhoids |□ Abdominal pain/cramps |
Notes: ______________________________________________________________________________
Genito-Urinary
|□ Pain on urination |□ Frequent urination |□ Urgent urination |□ Blood in urine |
|□ Wakes up to urinate |□ Burning urination |□ Kidney stones |□ Urinary tract infection |
|□ Sores on genitals |□ Impotence |□ Nocturnal emission |□ Prostatitis |
|□ Testicular pain |□ STDs |□ Decreased libido |□ Unable to hold urine |
Notes: ______________________________________________________________________________
Gynecological (women only)
|___ Number of pregnancies |□ Currently pregnant |□ Trying to become pregnant |
|___ Number of births |□ PMS |□ Painful menstruation |
|___ Number of abortions |□ Menstrual clots |□ Light periods |
|___ Number of miscarriages |□ Heavy periods |□ Irregular periods |
|___ Age of first menses |□ Vaginal discharge |□ Vaginal dryness |
|___ Duration of menses |□ Uterine fibroids |□ Endometriosis |
|___ Days between menses |□ Spotting between periods |□ Breast lumps |
|___ Date of last PAP |___ Age of menopause |□ On birth control |
Notes: ______________________________________________________________________________
Neurological/Psychological
|□ Seizures |□ Poor balance |□ Paralysis |□ Stroke |
|□ Lack of coordination |□ Poor memory |□ Susceptible to stress |□ Anxiety |
|□ Depression |□ Panic attacks |□ Irritability |□ Concussion |
|□ ADD/ADHD |□ Seasonal Affective Disorder |□ Easily worried |
□ Other: _____________
Notes: ______________________________________________________________________________
Please describe your typical daily diet:
|Morning |Afternoon |Evening |
| | | |
| | | |
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How much water do you drink per day? ___________________
Check the products that are used: □ Cigarettes □ Alcohol □ Coffee □ Tea □ Soft drinks
If yes, how much? ____________________________________________________________________
Please describe any use of drugs for non-medical purposes: ___________________________________
Do you have a regular exercise program? __________________________________________________
Do you have any occupational stress (chemical, physical, psychological)? _________________________
____________________________________________________________________________________
Patient Signature: _____________________________________ Date: ________________________
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