The Rest Stop Clinic Patient Health History
Name: _________________________________________DOB: _________________
Phone __________________________ Alt Phone: ____________________________
Email: ________________________________________________________________
Address: ______________________________________________________________
Emergency Contact: _________________________Phone: _____________________
Allergies: ______________________________Pregnant: Yes / No / Maybe
Taking Blood Thinning Medications: No/Yes add name: ________________________
Primary Health Concern: ___________________________________________________ Rating on 1-10 Scale: ______
Past Treatments for this condition: _________________________ Effectiveness of Treatment on 1-10 Scale: _______
Secondary Health Concern: _________________________________________________Rating on 1-10 Scale: _______
Past Treatments for this condition: __________________________Effectiveness of Treatment on 1-10 Scale: _______
Symptoms That Best Describe My Condition
Pain
___ No Pain
___Sharp
___Cramping
___ Radiating
___ Distending
___Burning
___ Cold
___ Heavy
___ Dull
Location of Pain
___ No Pain
___ Head: Top/Back/Front/Side
___ Back: Upper/Lower/Middle
___ Arms: Shoulder/Elbow/Wrist R/L
___ Legs: Hip/Knee/Ankle/Foot R/L
___ Chest: Center/ Sides
___ Abdominal: Upper/Middle/Lower
___ Whole Body Aches
___ One Sided Pain on Right/Left
Neurosensory
___ No Neuro Concerns
___ Migraines / Headaches
___ Dizziness / Vertigo
___ Tremors: Fine/Gross
___ Speech Impairment
___ Hearing Impairment
___ Visual Impairment
___ Decreased Sensitivity
___ One Sided Paralysis R/L
Sleeping
___ No Sleeping Concerns
___Insomnia
___Hypersomnia
___Difficulty Falling Asleep
___Difficulty Staying Asleep
___ Not Feeling Rested
Urination
___ No Urination Concerns
___ Frequent: Day/Night
___ Incontinence: Day/Night
___ Oder: Foul/Sweet
___ Painful
___ Color: Clear/Yellow/Red
Appetite
___ Good Appetite
___ Poor Appetite
___ Crave Cold Foods
___ Crave Hot Foods
___ Pain After Eating
___ Pain Before Eating
___ Difficulty Swallowing
___ Acid Reflux
Skin
___ No Concerns
___ Redness/Rash
___ Bruising
___ Dryness
___ Acne/Oily
___ Scaling/Flacking
___ Wounds
___ Temp: Hot/Cold
Bowels
___No Bowel Concerns
___ Constipation
___ Diarrhea
___ Loose Stools
___ Incontinence
___Color: Brown/Black/Pale
Sweating/Fever/Chills
___ No Abnormal Sweating
___ No Fever or Chills
___ Night Sweats
___ Spontaneously Sweating
___Profusely Sweating
___ Fever: Afternoon/Night
___ Chills: Afternoon/Night
___ Fever & Chills Alternating
Emotional
___Happy and Joyful
___ Depressed/ Sad
___ Agitated/Angry
___ Forgetful
___ Disorientated
___ Apprehensive
___ Fearful
___ Worried/Anxious
___ Grieving
Male or Female
___ No Sexual Concerns
___ Menstrual Heavy
___ Menstrual Light
___ Menstrual Painful
___ Metaphase
___ ED
Cardio/Respiratory
___ No Cardio/Respiratory
___ Chest Pain
___ Edema in Lower Legs
___ Poor Circulation
___ Short of Breath
___ Cough
___ Asthma
___ Fluid Retention
Your signature on this page indicates you have received, read, and are in agreement with, the consent to
treat and privacy notice provided. You understand the services you partake in during the course of your
treatment from The Rest Stop, Eastern Shore, River Restorative Therapies and Julie Lynch L.Ac. If you are
under the age of 18, then a parent/guardian must sign this form.
I acknowledge that I have read and understand the Notice Privacy Policy and Release of Liability provided to me.
____________________________________
___________________________________
Printed Name of Patient
Patient or Guardian Signature
____________________________________
__________________________________
Witness
Date