Kathryn Martin, RAc, RMT: Chiropractic Associates Clinic,
1127 Lakewood Crescent, Regina, SK, S4X 3S3
Acupuncture Health History Form
Date of first appointment:_____________
Please print, fill out and bring to your first appointment
Name ________________________________________________________________________________
Date of Birth ___________________________ Occupation _____________________________________
Mailing Address _______________________________________________________________________
Phone number _______________________ Email address _____________________________________
Emergency Contact Name _______________________ Relationship _____________________________
Emergency Contact phone number (H) _____________ (C) ______________ (W) ___________________
Have you received massage before? Y N
Have you received acupuncture before? Y N
Are you being treated by any other health practitioners? ______________________________________
Do you smoke? Y N Are you currently pregnant? Y N
Have you consumed any alcohol or pain meds in the last 12 hours? Y N
What is your Primary Concern? ___________________________________________________________
Have you consulted a medical doctor about this concern? Y N
When did it begin? _____________________________________________________________________
Has it changed? How so? ________________________________________________________________
What makes it better? ___________________ What makes it worse? ____________________________
Do you experience pain, numbness or itch? Where? Please
indicate on chart__ _____________________________________
How would you describe your pain (e.g. burning, dull ache, sharp,
moving)? _____________________________________________
Please mark your current level of pain:
0/_____________________________________________/10
Please mark your current level of stress
0/______________________________________________/10
Please mark your current level of activity: 0/_____________________________________________/10
Do you perform cardio exercise? Y N Do you perform strengthening exercises? Y N Do you stretch? Y N
During exercise, do you experience dizziness, headaches, difficult breathing, chest pain, extreme muscle
soreness or weakness? Y N Please indicate: ________________________________________________
Kathryn Martin, RAc, RMT: Chiropractic Associates Clinic,
1127 Lakewood Crescent, Regina, SK, S4X 3S3
Do you experience vivid dreams or nightmares? Y N What time do you go to bed? ______What time
do you fall asleep? _____ What time do you wake up? ________ Do you wake during the night? Y N
How many servings do you consume in a day? Water _____ Coffee/tea ______ Alcohol __________
Please list any allergies you have (include symptoms you experience):____________________________
_____________________________________________________________________________________
Please list any surgeries or traumatic injuries you have experienced: _____________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please list any medications/herbs/supplements/vitamins you are currently taking, and your reason for
taking them: __________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please indicate any of the following body systems, diseases or symptoms which you have experienced:
Nervous System:
O Seizures O nerve compression O nerve lesion O MS O Parkinson’s disease O Alzheimer’s disease
O Radiculitis O stroke O Other ____________________________
Emotional:
O anxious O easily stressed O easily angered O grief O fearful O depressed O easily frustrated
O easily irritated O relaxed O hard time turning off brain O manic O other____________________
Skin/hair/nails:
O Itchiness or dryness O eczema/psoriasis O acne O bruise easily O hives O rashes
O changes in skin texture O ulcerations O hot flashes O night sweats O loss of hair
O easy/spontaneous sweating O dandruff O nails break or bend easily O spots on nails
O grooves in nails
O other ____________________________________________
Eyes:
O sore eyes O eyestrain O colour blindness O spots/floaters O cataracts O glasses
O poor vision O blurry vision O red/burning/itchy eyes O night blindness O other ____________
Kathryn Martin, RAc, RMT: Chiropractic Associates Clinic,
1127 Lakewood Crescent, Regina, SK, S4X 3S3
Head:
O sensation of a lump in throat O sore throat O dry mouth or throat
O frequent clearing of throat O teeth problems O gum problems O swollen glands
O copious saliva O swollen glands O sores on lips or tongue O dizziness O nose bleeds
O grinding teeth O facial pain O facial paralysis O enlarged lymph glands O migraines/headache
O
sinus
issues
O
bitter
taste
in
mouth
O
metallic
taste
in
mouth
O low-pitch ringing in ears O high-pitch ringing in ears O poor hearing
O earaches
O mucous/phlegm (colour: ________) O other ____________
Lungs:
O cough O pneumonia O phlegm (colour:___) O hay fever or allergies O asthma O sinus issues
O bronchitis O tight chest O difficult breathing when lying down O COPD O other ___________
Heart:
O high blood pressure O high cholesterol O heart palpitations O low blood pressure O fainting
O stiff neck
O chest pain or tightness O cold hands or feet O difficult breathing
O irregular heart beat O swelling in hands/ankles/feet O poor circulation
O other _______
Liver:
O scirrhosis
O hepatitis
O fatty liver
O gall stones
O other ___________________
Kidney and Genito-urinary:
O wake up to urinate ____/night time _______)
O painful urination
O unable to hold urine
O urgent urination
O frequent urination
O blood in urine O excessive or scanty urination
O bedwetting O kidney stones O STD
O Painful/itchy genitalia O genital lesions or discharge
O impotency O decreased/excessive libido O other_____________________
Gynecological:
O clotted menses
O vaginal sores
O vaginal discharge O breast lumps O scanty periods
O menopause
O irregular periods O painful periods O other_____________________________
O Flow Description (colour, consistency, volume) _____________________________________________
O Most Recent Menses _____________ O Duration of Menses ________ O Age of First Menses _______
O Birth Control Type __________________________ O How long have you been using it? ___________
O Date of most recent pap smear ________ O Currently Pregnant? Y N
O Currently Nursing? Y N
O Number of Pregnancies _____ O Number of Births _____ O Number of miscarriages/abortions ______
O Number of premature births ________
Blood:
O anemia
O clot too easily
O other ____________
O difficulty clotting O history of thrombosis O blood infection
Kathryn Martin, RAc, RMT: Chiropractic Associates Clinic,
1127 Lakewood Crescent, Regina, SK, S4X 3S3
Digestion:
O nausea O gas O vomiting O abdominal pain or cramps O belching O hiccoughs O sensitive abdomen
O bad breath O diminished appetite OiIncreased appetite O hemmorhoids O rectal pain O itchy anus
O black stool O bloody stool O diarrhea O constipation O alternating loose stool/constipation O difficult
elimination O How often do you use laxatives? Type: _________________ O other ________________
Musle/Joints/bones:
O neck pain O spinal curvature O weakness O muscle pain O difficulty walking O body heaviness O TMJ
O body aches/stiffness
O joint pain (where) _______ O back pain (where)___________
O osteoporosis O bone pain O disc degeneration O artificial joints O pins O other _________________
Immune System:
O often ill O autoimmune disease O allergies? to what? Symptoms: _____________________________
O Chronic Fatigue O fibromyalgia O HIV/Aids O cancer
O diabetes
O Graves’ Disease
O other __________________________________________________________
Section 8(1) of Alberta’s Acupuncture Regulation stipulates that an acupuncturist shall not undertake the care and
treatment of a person unless: a) that person has already consulted with a physician about the condition for which
care and treatment from the acupuncturist is being sought; b) that person has informed the acupuncturist that a
physician or dentist has been consulted about the condition; and c) the client has completed a client consultation
form.
Has the client consulted with a physician about the condition for which acupuncture treatment is now being
sought? ___Yes ___No
The information I have provided on this health history form is true and complete to the best of my knowledge.
Client name: _________________________
Client signature: _______________________________