Health history form



|Patient Information |Contact Information |

| | |

|Date______________________________________ |Home phone ____________________________________ |

|Name_____________________________________ |Work phone ____________________________________ |

|Address___________________________________ |Other/cell phone _________________________________ |

|City State Zip______________________________ |Email _________________________________________ |

|Age__________ Birthdate ___________________ | |

|Occupation _______________________________ |Another person we may contact if needed: |

|Company name ____________________________ |Name ________________________________________ |

|Primary physician __________________________ |Relationship___________________________________ |

|Physician phone number______________________ |Home phone ___________________________________ |

|How did you hear about us? Please give person’s name, specific ad, |Work phone____________________________________ |

|etc________________________ | |

|Health History |

| | |

|What are your primary concerns for coming in for treatment? |Check symptoms you have or have had in the last year: |

|1- _________________________________________ |Depression |

|2 - ________________________________________ |Difficulty in focusing |

|3 - ________________________________________ |Dizziness |

| |Easily startled |

|How is your sleep? __________________________ |Excessive worry |

|___________________________________________ |Excessive anger |

| |Excessive fear |

|How is your digestion? ________________________ |Fatigue/tiredness |

|____________________________________________ |Headaches |

|List medications or food supplements you are taking. |Loss of sleep/poor sleep |

|____________________________________________ |Loss or gain of weight |

|____________________________________________ |Nervousness/irritability |

|List serious illnesses, accidents or surgeries. |Overwhelmed by life |

|____________________________________________ | |

|____________________________________________ |Check conditions you have or have had in the past: |

| |AIDS |

|Check illnesses that have occurred in blood relatives. |Allergies |

| |Anemia |

|χ Diabetes χ High blood pressure χ Stroke |Arthritis |

|χ Cancer χ Heart disease χ Kidney disease |Bleeding disorders |

| |Breast lump |

| |Cancer |

| |Diabetes |

| | |

| |How long has it been since you have had a complete medical exam? |

| |_____________________________ |

|Health History…continued |

|Check symptoms you have or have had in the last year: | |

| |CARDIOVASCULAR |

|MUSCLE/JOINT/BONES |Chest pain |

|Tremors or Cramps |Hardening of arteries |

|Swollen joints |High or low blood pressure |

|Pain, weakness, numbness in: |Pain over heart |

|Arms or Hips |Poor circulation |

|Back or Legs |Previous heart attack |

|Feet |Rapid/irregular heart beat |

|Neck |Swelling of ankles |

|Hands | |

|Shoulders |GASTROINTESTINAL |

|Other__________________ |Belching, gas or bloating |

| |Colon trouble |

|EYES/EAR/NOSE/THROAT/RESPIRATORY |Constipation |

|Asthma/wheezing |Diarrhea |

|Blurred or failing vision |Difficulty swallowing |

|Difficulty breathing |Distention of abdomen |

|Earache |Excessive hunger |

|Enlarged glands |Gall bladder trouble |

|Eye pain |Hemorrhoids (piles) |

|Frequent colds |Indigestion |

|Hay fever |Nausea |

|Hoarseness |Pain over stomach |

|Gum trouble |Poor appetite |

|Nose bleeds |Vomiting |

|Loss of hearing | |

|Persistent cough | |

|Ringing in ears |FOR MEN ONLY |

|Sinus problems |Erection difficulties |

| |Penis discharge |

|SKIN |Prostate trouble |

|Boils | |

|Bruise easily | |

|Dry skin |FOR WOMEN ONLY |

|Itching/rash |Bleeding between periods |

|Sensitive skin |Clots in menses |

|Sore won't heal |Excessive menstrual flow |

|Sweats |Extreme menstrual pain |

| |Irregular cycle |

|GENITO/URINARY |Menopausal symptoms |

|Blood/pus in urine |PMS |

|Frequent urination |Previous miscarriage |

|Inability to control urine |Scanty menstrual flow |

|Kidney infection/stones |Could you be pregnant?____________ |

|Lowered libido | |

|Signature |

| |

|The information on this form is correct to the best of my knowledge. |

| |

|Signature___________________________________________________________ Date ______________________ |

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Lowry Community Acupuncture

8609 Lyndale Ave S Suite 105f Bloomington, MN 55420

952-994-6585

Health History Questionnaire and Registration

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