JUDY ROSENFELD, MPH
Lynne Budde Sheppard M.A., L. Ac 3710 168th St NE, Suite A101, Arlington, WA 98223 360-653-3403
Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. My ability to diagnosis and treat your condition is based on a complete health history. All of your answers are completely confidential. This information will not be released to any person except with your authorization.
Health History Questionnaire Date __________/ __________/__________
|Name |
|Address Street City/State/Zip code |
| |
|Home phone Work phone Email address |
|Date of Birth Age Occupation |
|Height Weight Family Physician Phone |
|Emergency contact Emergency contact phone Relationship |
|Referred by Have you ever been treated with acupuncture before? Would you like to receive an email newsletter? |
What is the main problem (s) you would like help with? ______________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
When did the problem begin? (Date)___________________Is it getting better or worse? _____________
Do you know what caused the problem? ____________________________________________________
______________________________________________________________________________________
Have you been given a diagnosis for this problem? If so, what is it?______________________________
______________________________________________________________________________________
What kinds of treatment have you tried? ____________________________________________________
______________________________________________________________________________________
Current/Past Medical History (Please check if you currently have, or have had in the past. Include date)
( AIDs/HIV ( Diabetes ( Multiple Sclerosis ( Thyroid Disorder
( Alcoholism ( Emphysema ( Mumps ( Tuberculosis
( Allergies ( Epilepsy ( Pacemaker ( Typhoid Fever
( Appendicitis ( Goiter ( Pleurisy ( Ulcers
( Arteriosclerosis ( Gout ( Pneumonia ( Venereal Disease
( Arthritis ( Heart Disease ( Polio ( Whooping Cough
( Asthma ( Herpes ( Rheumatic Fever ( Tonsillectomy
( Birth Trauma ( Hepatitis ( Scarlet Fever ( Other (Specify)
( Cancer ( High Blood Pressure ( Seizures _________________________
( Chicken Pox ( Measles ( Stroke _________________________
( Migraines
Surgeries (Type and date)____________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Significant Trauma (Physical or emotional—auto accidents, falls, divorce, death in family. Please include date.)
_____________________________________________________________________________________________
Do you have any scars? Where? Are they painful? _______________________________________________________________________________________________________________________________
Dental Work (Type and date)_____________________________________________________________________
Family Medical History ( Allergies ( Alcoholism ( Diabetes ( Seizures
( Arteriosclerosis ( Cancer (type) ( Heart Disease ( Stroke
( Asthma ____________ ( High Blood Pressure ( Other
( Depression _________________
Please list the medications taken in the last two months. (Include medications, vitamins, herbs, etc.)
______________________________________________________________________________________
______________________________________________________________________________________
Do you experience occupational stress? (Chemical, physical psychological)_______________________
______________________________________________________________________________________
Do you exercise? (What type and how often)________________________________________________________
Please describe your typical meal for:
Breakfast:_____________________________________ Snacks____________________________________
Lunch________________________________________ Snacks___________________________________
Dinner_______________________________________ Snacks___________________________________
Do you smoke cigarettes? (Yes/no)___________ If yes, how many per day (week)________________
Do you drink alcohol? (Yes/no)______________ If yes, how much per day (week)________________
How much coffee, tea or cola do you drink per day? ______________________________________________
Please describe any drug use:________________________________________________________________
PLEASE CHECK ANY SYMPTOMS YOU HAVE HAD IN THE LAST 3 MONTHS
|General |( Psoriasis |( Cataracts |
|( Chills |( Hives |( Eye dryness |
|( Fever |( Acne |( Excessive tears |
|( Sweat easily |( Recent moles |( Discharge from eyes |
|( Night sweats |( Hair loss |( Poor hearing |
|( Localized weakness |( Dandruff |( Ringing in ears |
|( Bleed or bruise easily |( Fungal infections’ |( Hearing aid |
|( Peculiar tastes or smells | |( Earaches |
|( Strong thirst (for hot or cold drinks) |( Other hair or skin problem:___________ |( Discharge from ears |
|( Fatigue |________________________________ |( Nose bleeds |
|( Sudden energy drop | |( Sinus problems |
|Time of day?___________________ |Head, Eyes, Ears, Nose, Throat |( Excessive phlegm |
|( Edema Where?_________________ |( Dizziness |( Grinding teeth |
|( Poor sleep |( Migraines |( Jaws Clicks |
|( Tremors |( Headaches |( Concussions |
|( Poor balance |Location:________________________ |( Recurrent sore throats |
|( Cravings |( Facial Pain |( Hoarseness |
|( Change in appetite |Location:________________________ |( Enlarged thyroid |
|( Poor appetite |( Glasses |( Swollen glands |
|( Weight gain |( Poor Vision |( Sores on lips or tongue |
|( Weight loss |( Night blindness |( Gum problems |
|Skin and Hair |( Blurry vision |( Teeth problems |
|( Rashes |( Color blindness |( Other head or EENT problems: |
|( Itching |( Blind field |_________________________________ |
|( Change in hair or skin |( Spots in front of eyes |_________________________________ |
|( Ulcerations |( Eye pain |____________________________ |
|( Eczema |( Eye strain | |
| | | |
| | | |
| | | |
|Cardiovascular |Genito-Urinary |Musculoskeletal |
|( High blood pressure |( Pain on urination |( Neck Pain |
|( Low blood pressure |( Urgency to urinate |( Shoulder pain |
|( Chest discomfort/pain |( Frequent urination |( Back pain |
|( Heart palpitations |( Blood in urine |( Elbow pain |
|( Cold hands or feet |( Decrease in flow |( Hand/wrist pain |
|( Swelling of hands |( Unable to hold urine |( Hip pain |
|( Swelling of feet |( Dribbling |( Knee pain |
|( Blood clots |( Kidney stones |( Foot/ankle pain |
|( Fainting |( Impotency |( Muscle pain |
|( Difficulty in breathing |( Change of sexual drive |( Muscle weakness |
| |( Genital itching | |
|( Other heart/vessel |( Sores on genitals |( Other______________________ |
|problems:___________________________________________|( Waking to urinate at night? |_____________________________ |
|____________________________________________________|How often?________________ |Neuropsychological |
|_________ | |( Seizures |
|___________________________ |(Other Genital/urinary system |( Areas of numbness |
|Respiratory |problems_________________________ |( Tics |
|( Cough |___________________________________________________|( Sleep disorder |
|( Asthma/wheezing |___ |( Concussion |
|( Pain with a deep breath | |( Bad temper |
|( Difficulty in breathing when |Pregnancy and Gynecology |( Irritability |
|lying down |Number of pregnancies______________ |( Depression |
|( Production of phlegm |Number of births__________________ |( Frustration |
|Color of phlegm?_________________ |Number of premature births__________ |( Sadness |
|( Coughing blood |Number of miscarriages_____________ |( Anxiety |
|( Pneumonia |Number of abortions_______________ |( Easily susceptible to stress |
|( Bronchitis |Age at first menses________________ |( Vertigo |
| |Days between menses______________ |( Loss of balance |
|( Other lung |Duration of menses (days)___________ |( Poor memory |
|problems____________________________________________|Date of first day of last menses: |( Substance abuse |
|________________________________ |__________________________ |( Abuse survivor |
|Gastrointestinal | | |
|( Vomiting |( Heavy periods |Have you been ever been treated for emotional |
|( Nausea |( Light periods |problems? |
|( Acid regurgitation |( Painful periods |( Yes ( No |
|( Bad breath |( Irregular periods | |
|( Hiccup |( Changes in body/psyche prior |Have you ever considered or |
|( Bloating |to menstruation |Attempted suicide? |
|( Diarrhea |( Clots |( Yes ( No |
|( Constipation |( Menopause | |
|( Chronic laxative use |Age_______ Year_________ |Other neurological or psychological |
|( Blood in stools |( Vaginal discharge |Problems:__________________________ |
|( Black stools |( Postcoital bleeding |___________________________ |
|( Mucous in stools |( Vaginal sores |___________________________ |
|( Abdominal pain or cramps |Date of last Pap _____________ |***Any health issues not |
|( Gas |( Breast lumps |mentioned on this form: |
|( Rectal Pain |( Nipple discharge |____________________________ |
|( Burning anus | |____________________________________________________|
|( Itchy anus |Do you practice birth control?___________ |____________________________________________________|
|( Hemorrhoids |__________________________ |____________________________________ |
|( Anal fissures | |____________________________________________________|
| |What type and how long?_______________ |________________________________ |
|( Other GI problems:________________ |________________________________ | |
|____________________________________________________|___________________________ | |
|_____________________________ |___________________________________________________| |
| |______________________________ | |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- patient information constipation
- m29 1 part 5 l
- approach to the patient with gas and bloating
- understand concepts in medicine so you can solve problems
- a 45 year old female presents with a complaint of
- leaky gut syndrome
- the digestive system
- integrative psychotherapy of omaha
- judy rosenfeld mph
- from saji meetup