Positive Chinese Medicine Inc.
Date: ____________________
Health History Summary
First Name_________________ Last Name ____________________ Age__________ Birth Date_________________
Address _________________________________________________________________________________________________
_______________________________________________________________________ Postal Code _______________
Phone (Cell) _______________________ (Home) ________________________ (Work) ____________________________
E-mail_____________________________________________
Occupation_________________________________________
Employer___________________________________
Marital Status: Sgl Mar Div Sep Wid Other:_________
Number of Children __________________________
Emergency Contact__________________________________
Relation____________________________________
Phone_____________________________________________
How did you find out about my office? Please circle.
Friend, Fertility Clinic, Medical Doctor, Flyer, Phone Book, Website
(ivf.ca), (acufinder.com), (acupuncture-fertility-ivf.com), Magazine, Other:_____________________
Your Current Health Problems
What is your main reason for coming in today? __________________________________________________________________
List in order of importance other health problems that are troubling you:
1) _________________________________________________________________
How long? _______________________
2) _________________________________________________________________
How long? _______________________
3) _________________________________________________________________
How long?________________________
Have you had acupuncture before? Yes No Have you had Chinese herbs before? Yes No
Please circle all of the following complimentary health care practitioners you have seen:
Fertility specialist Naturopathic Doctor
Chiropractor Massage Therapist
Osteopath
Other:_____________________
What were the results? ________________________________________________________________
________________________________________________________________________________________________________
General Health History
What is the general state of your health? Excellent_______ Good_______ Average_______ Fair_______ Poor_______
What is your current level of energy from 1 to 10 (where 10 is the best you have ever felt)? :__________
What is your current approximate weight? _________ One year ago?_________ Ideal weight?_________ Height?_________
Please list the 3 most significant stressful events in your life:
1) _______________________________________________________________
Date: ___________________
2) _______________________________________________________________
Date: ___________________
3) _______________________________________________________________
Date: ___________________
Are any of these situations continuing to impact your life? Yes / No (If yes, please circle number.)
Are you currently working with a professional counselor, psychologist, social worker, pastor or other
therapist?_______________________________
Have you in the past?__________________
When?____________________
Do you have any allergies to any drugs, herbs, foods, animals or other? Yes / No
Please specify: ____________________________________________________________________________________________
Have you had any major injuries? If so, what happened and when? __________________________________________________
Previous surgeries and hospitalizations (include dates) ____________________________________________________________
Rate the following symptoms from 1 to5 ( 5 being worst )
Xin ( Heart ) Condition
Palpitations ____ Insomnia____
Chest Pain____ Cankers____
Gan ( Liver ) Condition
Depression____Anger____PMS____Breasts Tenerness or Pain____High prolactin Levels_____Bitter Taste in
Mouth____Dry or Tiredness of Eyes____High Blood Pressure_____Neck /Shoulder Tenssion____Muscle
Twiching____
Pi (Spleen) Condition
Poor Appetite____ Craving Sweet_____Poor Digestion ____ Bloating____ Loose Stools____Abdominal
Pain____Fatigue___Water Retention_____ Cold Hands & Feet____ Bruise Easily____Feel Heavinss in the head/
Body____Varices Veins_____Worry/Over-thinking____Low Blood Pressure____Dizzy ness____Lighter
Menstruation____Mid Cycle Spotting____Alleries____Hypothyroidism____Anemia____
Fei ( Lung ) Condition
Cough____Shortness of Breath_____Sinus_____Skin Rashes____Snoring____Asthma_____Catch Cold easily____
Shen ( Kidney ) Condition
Ringing in ears____Hearing loss____Poor Memory____Loss of Hair____Hot Flash_____Lower Part of Body
Swelling_____Frequent Urinatioon______Incontinence____Bladder Infection_____Feel Cold____Low Libido____
Which of the following do you currently use? (Please indicate how much, how often and how long.)
Alcohol
_______________________________
Tobacco
________________________________
Hormones
_______________________________
Coffee
______________________________
Antacids
_______________________________
Tea
________________________________
Sedatives
_______________________________
Laxatives
________________________________
Other Medications (Please give name, dose, and amount of time on the medication)
______________________________________________
_______________________________________________
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Vitamins/Herbs:
Any other supplementation:
______________________________________________
_______________________________________________
Family History
Mother
Father
Sibling
Grandparent
Mother
Cancer
Kidney Disease
Tuberculosis
Diabetes
Heart Disease
Asthma
Stroke
Depression
High Blood
Other:
Pressure
_____________
Who do you currently live with? Spouse____
Partner____
Parents____
Are you currently in a happy and supportive relationship? (Please circle.)
Friends____
Very
Mostly
Father
Sibling
Children____
Somewhat
Grandparent
Alone____
No
What is your weakest organ system and why? (Example: Digestive, Immune, etc.)______________________________________
Personal Habits
Do you exercise? Yes / No If yes, what do you do and how often?
_______________________________________________
On a scale of 1-10, how would you rate the quality of your sleep (10 being great) __________________
Do you have a problem falling asleep? ____ Staying asleep? ____ How much do you sleep? _____hours
How many hours do you think you need? _____ Do you wake refreshed?________________
How is your body temperature, compared to others? Warmer
Do you enjoy your work? Yes/No
Cooler
Average
Do you take vacations? Yes/No
How often do you get colds, flu, sore throats in a year? ____________________________________
Kidneys and Bladder
Have you had a bladder infection? Yes / No
How often? ________
How was it treated?
Do you have any burning sensation during or after urination? Yes / No Have you in the past?
What color is your urine? (i.e. dark yellow, bright yellow, cloudy, pale, clear)
__________________
__________________
________________________________________
Does your urine have an odor (i.e. strong, sweet) ________________________________________________________________
Do you have any difficulty starting or stopping when urinating? Yes / No
Perspiration
Do you any difficulty perspiring? Yes / No Does your sweat have a strong odor? _______________________________
Do you perspire when exercising? Lightly Moderately Heavily
Do you perspire at times other than when you exercise? Yes / No When?____________________________________________
Digestion and Elimination
Do you have any problems with gas, bloating, or fullness after eating? Yes / No
How often is this a problem? Often Sometimes Never
How severe?____________________________________________
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How long have you had this problem?_________________
How often do you have bowel
movements?____________________
Do you ever have any blood, mucous or undigested food in your stool? _______________________________________________
Do you ever have black, tarry or gray stool? Yes / No
Do you ever have yellow or light colored stool? Yes / No
Do you ever have rectal itching? Yes/No
Are your stools formed or loose?
Do you ever have alternating constipation and diarrhea? Yes / No
Do you ever have to strain to pass stool? Yes / No
_________________________
If yes, how often? ________________________________
If yes, how often? _______________________________________
Do you pass gas (flatus) frequently?____________________ Do you burp frequently? ________________________________
Do your stools or gas have a strong disagreeable odor? Yes / No
Is there anything else you feel I should know about you?
_________________________________________________________________________________________________________
_________________________________________________________________________________________
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Additional information for fertility treatment patients
Date of last period_____________________________
Age of first menses_____________ Menstrual cycle length _____ days
Lasts _____ days
Are your cycles regular? Yes / No
If periods have stopped, at what age did they stop? _______
How is your flow? Heavy____ Moderate____ Light____
Color of the blood? Red___ Dark red___ Brown___ Pink___
Are there any clots? Yes / No
Any cramps with your period?
Do you have any spotting or bleeding between your periods? Yes / No
Yes / No
(If yes, does it happen every month?) _______________
Do you have any premenstrual symptoms? _____________________________________________________________________
Do you chart your basal body temperature? Yes / No
Do you ovulate on your own?
On day____ of the cycle
How is your sexual energy? Low___ Normal___ High____
Do you have vaginal dryness? Yes / No
Have you taken oral contraceptives? Yes / No
When?_________________ How long? __________________
Have you had an IUD? Yes / No
When?_________________ How long? __________________
Number of pregnancies________________ Number of abortions________________
Number of miscarriages_____________
Number of live births________________ Any problems getting pregnant? __________________________________________
Do you have discharge? Yes / No. If yes, what is the color? Yellowish
Does your discharge have any odor? Yes / No
White Transparent
Do you feel itchy? Yes / No
How long have you been trying to conceive?
Has he had a fertility workup? Yes / No
What were the results? _____________________________________________________________________________________
Indicate which of the following conditions you have or had and indicate “now” (N) or “past” (P)
N
P
N
P
N
P
N
STD
PCOS
Pelvic adhesions
Yeast infection
Endometriosis
Uterine fibroid
Pelvic Inflammatory Disease
Bladder infection
Polyps
Abnormal PAP
Blocked fallopian tube
P
Fertility treatment
Clinic name__________________________________________________ By Dr.___________________________
Month / Year_____________________________________________________________________________________________
Type of treatment___________________
Have you had any hormone tests performed? Yes / No
What were the result?______________________________________________________________________________________
Thank you for taking the time to fill in this lengthy questionnaire. It will be a valuable resource in understanding your health.
The information received here about you is strictly private and confidential
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Patient consent form
I _______________ (Name in print), voluntarily consent to receive (the following of my choosing), Acupuncture, Chinese Herbal
Medicine administered by Jinglan-Li Burns or Qi Dai who are registered to practice the specified treatment/ training. I understand
their training is in the specified treatment/ training and that they are not, nor claiming to be a medical doctor.
I understand that the evaluation given to me ( when receiving acupuncture) is an energetic assessment of the functioning of any
organs and the Qi ( energy) moving in the Acupuncture Meridian Network; it in no way purports to be, or replaces allopathic
(western) medical evaluation, diagnosis, or treatment.
I shall provide a full history and description of complaints which is complete and accurate. I understand that the need for
communication with all of my health care providers regarding my health status is ongoing and necessary. I understand that no
guarantee has been made concerning the use and effects of Acupuncture, Chinese Herbal Medicine. I understand that I may stop
treatment at any time.
I understand that Acupuncture is the insertion of fine sterile needles, with or without the addition of electrical stimulation, through
the skin, and / or the application of heat to regulate and balance Qi, improve organ function and improve health.
I acknowledge that, although rare, certain side effects may result from Acupuncture, heat therapy and Chinese Herbal Medicine.
These may include minor bruising, minor bleeding, some pains at the site of needle insertion, dizziness or fainting. These events
are unusual and of short duration. Rare but potential side effects of heat therapy include heat discomfort or burning. Side effects of
Chinese Herbal Medicine are rare but may include allergic reactions. Strong cleansing responses to Acupuncture and Chinese
Herbal Medicine may also occur. Potential effects will be addressed.
I am choosing Acupuncture and /or Chinese Herbal Medicine as an exercise of my right to freedom of choice in the healing arts.
Signature: ____________________________________________________________
Date:_____________________________
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