Longevity Acupuncture & Chinese Herbal Medicine • Complementary Medicine • Preventative Medicine
7000 SW 62nd Ave Suite 204 South Miami FL 33143
TEL: 305-772-4386 F A X : 7 8 6 -360-3390
Health History Form
Name
V. Yi Bin Shou-Litman, A.P., Dipl. OM
Age
Sex
Referred by
Date
Chief Complaint:
Secondary Complaints:
Your Primary Physician
Diagnosis of your condition
Medications:
X-Ray/ MRI/ Lab Test Results:
Past History: ( prior illnesses, injuries, medical conditions and procedures )
Family History: 0 High Blood Pressure
0 Cancer
0 Diabetes
0 High Cholesterol
0 Coronary Heart Disease
Symptoms you currently have or have had in the past year.
General
0 Chills
0 Low energy
0 Dizziness
0 Allergies
0 Fatigue
0 Fever
0 Excess thirst
0 Insomnia
0 Stressed
0 Numbness
0 Spontaneous sweat
0 Night sweat
0 Lack of sweat
0 Aversion to heat
0 Aversion to cold
Weight
0 Underweight
0 Overweight
0 Normal for height
Head and Neck
0 Blurred vision
0 Heaviness in the head
0 Headache
0 Phlegm in throat
0 Cataract
0 Double vision
0 Earache
0 Ear discharge
0 Eye pain/ strain
0 Nasal discharge
0 Hearing loss
0 Hoarseness
0 Recurrent sore throat
0 Nosebleeds
0 Red/ inflamed eyes
0 Ringing in ears
0 Sinus problems
0 Sores on tongue
0 Taste change
0 Migraine
Respiratory
0 Asthma
0 Hay Fever
0 Persistent cough
0 Coughing blood
0 Shortness of breath
0 Recurrent bronchitis
0 Phlegm production
0 Difficult inhaling
0 Difficult exhaling
Cardiovascular
0 Chest pain
0 Tightness in chest
0 High blood pressure
0 Low blood pressure
0 Irregular heart beat
0 Poor circulation
0 Swelling of ankles
0 Varicose veins
0 Hypochondriac pain
Longevity Acupuncture & Chinese Herbal Medicine • Complementary Medicine • Preventative Medicine
7000 SW 62nd Ave Suite 204 South Miami FL 33143
TEL: 305-772-4386 F A X : 7 8 6 -360-3390
Gastrointestinal
0 Abdominal pain
0 Bloating
0 Belching
0 Gas
0 Constipation
0 Diarrhea / loose stools
0 Bloody stools
0 Difficulty swallowing
0 Poor appetite
0 Heartburn / reflux
0 Hemorrhoids
0 Indigestion
0 Stomachache
0 Nausea
0 Vomiting
Skin and Hair
0 Dry skin
0 Acne
0 Bruise easily
0 Bags under eyes
0 Discoloration
0 Itchiness
0 Hive
0 Broken blood vessels
0 Premature gray hair
0 Dry brittle hair
0 Brittle nails
0 Hair loss
Women Only
0 Abnormal pap smear
0 Bleed between periods
0 Irregular periods
0 Heavy periods
0 Endometriosis
0 Painful periods
0 Premenstrual tension
0 Breast lumps
0 Contraceptives
0 Sores on genitalia
0 Low libido
0 Vaginal discharge
0 Menopausal
0 Uterine prolapse
0 Facial hair
Genitourinary
0 Dilute urine
0 Dark urine
0 Blood in urine
0 Cloudy urine
0 Burning urine
0 Scanty urine
0 Profuse urine
0 Frequent urination
0 Poor bladder control
0 Urgency to urinate
0 Urinary retention
0 Bladder stone
0 Kidney stone
Emotional
0 Insomnia
0 Irritability
0 Anger
0 Disturbed dreams
0 Cry spells
0 Feel sad
0 Anxiety
0 Fear / phobia
0 Panic attack
0 Depression
0 Mood swings
0 Resentment
0 Obsessive-compulsive
0 Worry
Men Only
0 Genital pain
0 Impotence
0 Genital sores
0 Nocturnal emission
0 Low libido
0 Early ejaculation
0 Penis discharge
0 Lump in testicles
0 Enlarged prostate
Musculoskeletal
pain, weakness, numbness in
0 Arms / Elbows
0 Feet / Heels
0 Hands
0 Joints
0 Legs
0 Hips
0 Neck
0 Shoulders
0 Knees
0 Low back
0 Cold limbs
0 Pain all over
0 Weakness all over
0 Broken bones
Neurological
0 Fainting
0 Convulsions
0 Paralysis
0 Stroke
0 Drowsiness
0 Vertigo
0 Seizures
0 Tremor
Diet/ Lifestyle
0 Vegetarian
0 Healthy diet
0 Green leafy vegetables
0 Organic foods
0 Eat much red meat
0 Eat much dairy products
0 Drink alcohol
0 Drink coffee
0 Drink soda / diet soda
0 Use drugs
0 Smoke cigarettes
0 Sugar cravings
0 Iced water / beverage
0 Take steroids
0 Fast food
0 Preserved food
0 Fried food
0 Exercise regularly
0 Exercise excessively
Longevity Acupuncture & Chinese Herbal Medicine • Complementary Medicine • Preventative Medicine
7000 SW 62nd Ave Suite 204 South Miami FL 33143
TEL: 305-772-4386 F A X : 7 8 6 -360-3390
ACUPUNCTURE/HERBAL THERAPY CONSENT FORM
I had the opportunity to ask Acupuncture Physician Vivian Yi Bin Shou-Litman
questions and to inquire about the risks and benefits involved in the treatment of
Acupuncture and Herbal Therapy. I have been informed that acupuncture is a
generally safe treatment procedure with the use of disposable acupuncture
needles. However, in rare instances, side effects may occur, such as localized skin
irritation, bruising/hematoma, localized numbness, dizziness or fainting. Burns and
scarring are a potential risk of moxibustion and cupping.
Herbal therapy is considered safe in the practice of Traditional Oriental Medicine,
when prescribed by a well trained practitioner. Due to individual’s constitution,
possible side effects of taking herbs sometimes occur, which include nausea, gas,
headache, diarrhea, and rashes. I understand some herbs are contraindicated in
pregnancy.
I hereby acknowledge the receipt of information on the possible side effects of
acupuncture and herbal therapy as mentioned above.
Understanding this, I
authorize the above named practitioner to perform such treatments and to
administer such herbal medicine as in her/his opinion that is necessary or advisable
for me.
By voluntarily signing below, I acknowledge my consent to treatment, the risk and
benefits of acupuncture, herbal supplements and other procedures.
I hereby
release the practitioner from any liability which may occur as a result of the above
treatments. I intend this consent form to cover the entire course of treatment for
my present condition and for any future conditions for which I seek treatment.
I clearly understand and agree that all services rendered are my own financial
responsibility and I am personally responsible for payment at the time of services
rendered.
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