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 |

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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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