Today’s Date____/____/____
Please Print
D
M
Y
Name:__________________________________________________ Date of birth____/____/____ Age:____
(Last)
(First)
D
M
Y
Address: __________________________________________________________________________________
City: _____________________________ Province: _______________________Postal code: ______________
Tel: ________________Work:________________ Cell: ________________
Email: _______________________________ Would you like to receive email reminders? ________________
Occupation: _______________________ Gender: Male____ Female___ Height: _______ Weight: _____lbs
Relationship status: Single: ___ Common-law: ___ Married: ___ Separated: ___ Divorced: ___ Widowed: ___
Emergency Contact Person: ________________________ Relationship: _______________Tel:_____________
Patient Medical History
Check any you have had in the past:
___Diabetes
___High/low blood pressure
___Seizures
___Childhood illnesses
___Accident/trauma
___Hepatitis
___HIV
Other: ______________
___Cancer
___Bleeding Tendency
___Nervous Disorder
___Alcoholism
___Drug Addictions
___Mental illness
___Birth trauma
___Heart Disease
___Asthma
___Thyroid disease
___Epilepsy
___Allergies
___CVA (stroke)
___Fibromyalgia
___Cancer
___Asthma
___Epilepsy
___Allergies
___CVA (stroke)
___Heart Disease
___Seizures
___Herpes
___Hepatitis A/B/C
other: ______________
Family Medical History
___Diabetes
___High blood pressure
___Alcoholism
___Drug Addictions
___Mental illness
Are you currently taking any medication? Yes___ No___
If yes please list medications and for what conditions
1._______________________________________ 4._________________________________
2._______________________________________ 5._________________________________
3._______________________________________ 6._________________________________
Are you currently taking any supplements? Yes___ No___.
Please list: ________________________________________________________________________________
What medical diagnosis have you received for this condition: ________________________________________
Are you seeking other alternative therapies for your condition (if yes please list): ________________________
_________________________________________________________________________________________
Is this your first experience in Acupuncture? _____________________________________________________
Habits
Please indicate usage per day or per week:
Cigarettes _________________ per ______
Drugs
_________________ per ______
Main problem you would like help with: _______________________________________________________
__________________________________________________________________________________________
When did the problem begin (be specific): _______________________________________________________
To what extent does the problem interfere with your daily activity (work, exercise, sleep, sex, etc.)?
__________________________________________________________________________________________
__________________________________________________________________________________________
Any significant traumas? _____________________________________________________________________
Rate you Energy level on a scale of 1 to 10 (10 being the worst): _________
What time of day is your energy: Highest? ______________________ Lowest? _________________________
Do you fatigue easily? _______________________________________________________________________
On the following drawings, please clearly mark any areas of pain.
Musculoskeletal
___Joint pain/disorder
___Sore muscles
___Hip pain
___Difficulty walking
___Neck/shoulder pain
___Upper back pain
___Lower back pain
___Rib pain
What is the frequency of discomfort: ___________________________________________________
Rate you pain level on a scale of 1-10. Circle one.
Less Pain
1
2
3
4
5
6
7
Minimal
slight
moderate
8
More Pain
9
10
severe
Do you suffer from any of the following?
Please check all the following that pertain to you.
General
___ Fatigue
___ Recent weight loss/gain
___Easy bruising
___ Cold hands & feet
___Cold nose
___Cold low back
___Cold limbs
___Chills/fever
___Itching
___Rashes
___acne
___Eczema/ psoriasis
___Dry skin
___Dry nails
___Brittle nails
Other: __________________________________________________________________________
Emotions & Sleep
___Anxiety/worry
___Irritability/anger
___Depression
___Panic attacks
___Poor memory
___Mood swings
Other: ______________________________________________________________
Sleep:
___Fall asleep easily
___Lie in bed with eyes open
___Wake repeatedly
___Wake frequently to urinate
___Wake up not feeling rested ___Nightmares or frightening dreams
___Need medication or supplements to fall asleep
___Wake at specific times
___Vivid dreams
Eyes, Ears, Nose, Throat & Head
___Blurred vision
___Spots or floaters
___Dry eyes
___Itchy eyes
Other: _______________________________________________
Ringing in ears:
High pitch____
Low pitch___
___Sinus infection
___Post-nasal drip
___Frequent sore throat
___Frequent colds
___Nosebleed
___Nasal congestion
___TMJ
___Difficultly on inhalation
___Chronic cough
___ Feeling of a lump in the throat
___Coughing up phlegm
___Shortness of breath
___Tightness in chest
___Heaviness of the chest
___Palpitations
Other: _________________________________________________________________________
___Headaches
___Migraines
Frequency? _____
Duration of attacks? __________
Character of pain:
___Feels full/pressure
___ Dull/achy
___Throbs
___Visual aura
___Stiff neck
___Dizziness/vertigo
Other: _______________________________________________
___hair loss
___premature graying
Gastrointestinal
___Extreme appetite
___No appetite
Cravings for:
___Sugar
___Salt
___Tired after eating
___Gas
___Sour
___Bloating
___Nausea
___Reduced appetite
___Carbs
___Acid reflux
___Belching
___Heart burn
Bowl movements:
How often? ______time(s) day/week
Color of Stool: ________________________
___Diarrhea
___Constipation
___Loose stools
___Dry hard stools
___Alternate between soft to hard stools
___Early morning diarrhea
___Blood in stool
___Mucus in stool
___Pain/cramping
Other: _______________________________________
Fluid Metabolism & Urination
How many glasses per day do you drink of the following?:
Water___
Pop___
Coffee___ Tea___
Alcohol___
What temperature of beverage do you prefer? Hot___ Cold___ Room temperature___
How would you describe your thirst?
Thirsty often___
Have to force myself to drink___ Never thirsty___
Can’t quench my thirst___
Normal___
Sweating:
___Day time sweating ___Night time sweating
___Spontaneous sweating ___Related to exertion
Urination:
How often? ________times/day
___Cloudy urine
___Burning on urination
___Strong smelling urine
___Frequent urination
___Urgent urination
___Blood in urine
___Wake to urinate
Other: _____________________________________________________________________