Acupuncture Associates Clinic – Health History Questionnaire
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Kerry Briggs Acupuncture & Oriental Medicine 394 Atlantic Ave, Brooklyn 11217 AcuLaxer@gmail.com 303-882-5179 Name ________________________________________ DOB ____/____/____ [ ] M [ ] F Address ______________________________________ City __________________ State ____________ Daytime Phone (_____)_____________________ Evening Phone (_____)____________________________ Employer Name ______________________ Physician Name & Phone ________________(_____)________ Health Insurance___________________________________________________________________________ Policy/Group # _______________________________ ID # ________________________________________ (No Fault) Claim # __________________________ (No Fault) Insurance Phone # (_____)________________ Please list your Date Use scale below to indicate Please check the box below indicating reasons(s) for this first severity of each symptom, how much of the time you feel the visit or your noticed: “0” is none (no condition(s) in order symptom: symptoms) and 10 is severe. of importance: 0 1 2 3 4 5 7 8 9 1. ________________ 10 0-25% 26-50% 51-75% 76- 2. ________________ 0 1 2 3 4 5 7 8 9 100% 3. ________________ 10 0-25% 26-50% 51-75% 76- 4. ________________ 0 1 2 3 4 5 7 8 9 100% 10 0-25% 26-50% 51-75% 76- 0 1 2 3 4 5 7 8 9 100% 10 0-25% 26-50% 51-75% 76100% LIFESTYLE Do you exercise regularly? [ ] Yes [ ] No If yes, please describe: ________________________________________ Occupational stress factors (physical, psychological, chemical): _______________________________________ Please check the following habits that apply. How much, how often do you use them? Cigarette smoking Coffee, tea or cola Alcoholic Beverages ______________________ ______________________ ______________________ List medications taken within last two months (vitamins, drugs, herbs, etc.): __________________________ __________________________________________________________________________________________ Please mark painful or distressed areas on the chart below: Please describe the pain: _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ PLEASE PUT A CHECK NEXT TO ANY CONDITION YOU’VE EXPERIENCED IN THE LAST THREE MONTHS, CIRCLE THOSE YOU‘VE EXPERIENCED IN THE PAST. INDICATE THE LENGTH OF TIME YOU HAVE HAD THIS CONDITION. PAST MEDICAL HISTORY (PLEASE INCLUDE DATES) Allergies Rheumatic Fever Other Significant Cancer Surgeries illness/Trauma (describe) Diabetes Venereal Disease ____________________________ Hepatitis Thyroid Disease ____________________________ High Blood Pressure Birth Trauma (prolonged Heart Disease labor, forceps delivery, etc.) ____________________________ Seizures ____________________________ FAMILY MEDICAL HISTORY Allergies Cancer Seizures Diabetes Heart Disease Stroke Asthma High blood Pressure Other Poor appetite Weight gain Night Sweats Insomnia Weight loss Fever GENERAL Disturbed sleep Changes in appetite Chills Localized weakness Sweating easily Sudden energy drop (time of Cravings Tremors day) Strong thirst Bleeding or bruising easily Poor balance Rashes Eczema Recent moles Ulcerations Pimples Changes in texture of hair or Hives Dandruff skin Itching Hair loss SKIN & HAIR HEAD, EYES, EARS, NOSE, THROAT Dizziness Color blindness Recurrent sore throats Concussions Cataracts Nose bleeds Migraines Blurry vision Grinding teeth Glasses Earaches Sores on lips or tongue Spots in front of eyes Ringing in ears Facial pain Eye pain Poor hearing Teeth problems Poor vision Eye strain Headaches (where? when?) Night blindness Sinus problems Jaw clicks Dizziness High blood pressure Swelling of feet Low blood pressure Fainting Blood clots Chest pain Cold hands or feet Difficulty in breathing Irregular heartbeat Swelling of hands Phlebitis Cough Bronchitis Difficulty breathing when Coughing up blood Pain with deep inhalation lying down Asthma Pneumonia Excessive phlegm (color?) Nausea Belching Rectal Pain Vomiting Black stools Hemorrhoids Diarrhea Blood in stools Abdominal pain or cramps Constipation Indigestion Chronic la Gas Bad breath CARDIOVASCULAR RESPIRATORY GASTROINTESTINAL GENITOURINARY Pain while urinating Urgency to urinate Decrease in flow Frequent urination Unable to hold urine Impotence Blood in urine Kidney stones Sores on genitals Do you wake up at night to urinate? _________ If so, how often? ______________________________________ Any particular color to your urine? ______________________________________________________________ Any other genital or urinary problems? ___________________________________________________________ REPRODUCTIVE AND GYNECOLOGIC Premenstrual changes Heavy menstrual flow Premature births Menstrual clots Light menstrual flow Miscarriages Painful menses Irregular menses Abortions Unusual menses Other problems Age at first menses: _______ Age at menopause: _______ Number Duration of bleeding: ______ First of pregnancies: ______ Time between cycles: _____ day of last menses: ______ Do you practice birth control? ____ If so, what type? _________ For how long? ______________ MUSCULOSKELETAL Neck pain Back pain Hand/wrist pain Muscle pains Muscle weakness Shoulder pains Knee pain Foot/ankle pains Hip pain Seizures Poor memory Anxiety Dizziness Lack of coordination Bad temper Loss of balance Concussion Easily susceptible to stress Areas of numbness Depression NEUROPSYCHOLOGICAL COMMENTS Please list any other problems you would like to discuss: ____________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ ___________________________________________
