Dr. Michelle D. Wu
Acupuncture & Herbal Medicine Clinic
One Lake Bellevue Drive Suite 105
Bellevue, Washington 98005
Patient Name _______________________________________
Age _____
Phone: (425) 643-3758
Male / Female
Date of Birth ____/____/_____
Height ________________
Weight ____________
S.S. # ____________-__________-______________
Marital Status ________________________________
Phone (H) (__________)_________-____________
Phone (W) (__________)_________-______________
Address ___________________________________________________________________________________
City _______________________________________
State ________________ Zip ___________________
E-mail (Optional) ____________________________
Phone (Cell Opt.) (__________)________-___________
Employer __________________________________
Occupation ___________________________________
Spouse’s Name ______________________ Date of Birth ____/____/______ S.S. # _______-_____-______
Spouse’s Employer ___________________ Occupation ________________ Phone (W) ___________________
Family Physician ____________________________
Phone (__________)_________-__________________
Referred by ________________________________
Phone (__________)_________-__________________
Emergency Information
Please indicate who to notify in case of emergency
Name _____________________________________
Relationship ________________________________
Phone (H) (__________)_________-___________
Phone (W) (__________)_________-___________
Phone (C) (__________)_________-___________
Insurance Information
Insurance ____________________________________ 2nd Insurance___________________________
Subscriber’s Name _____________________________ Subscriber’s Name ____________________________
Date of Birth ____/____/______
Date of Birth ____/____/______
S.S # (or I.D#) _________________________________ S.S # (or I.D#)________________________________
Patient’s Name___________________________________________ Date ___________________________
Chief Complaint(s) Please indicate how long you’ve had the condition(s).
Other Complaint(s) Please indicate how long you’ve had the condition(s).
What kinds of treatments have you received?
List any Hospitalizations & Surgeries
Date
Place
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
List medications being taken (include dose)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Dr. Michelle D. Wu
Acupuncture & Herbal Medicine Clinic
One Lake Bellevue Drive Suite 105
Bellevue, Washington 98005
Phone: (425) 643-3758
Confidential Patient Health History
Name: ______________________________________________________
Date: ___/___/___
Please check if you have had (in the past three months):
General
[] Anemia
[] Fatigue
[] Fever
[] Weight Loss
[] Sweats
[] Chills
[] Drug Addiction
Skin and Hair
[] Rashes
[] Itching
[] Dandruff
[] Change in hair/skin texture
[] Ulcerations
[] Eczema
[]
[]
[]
[]
[]
[]
[]
Poor Appetite
Localized Weakness
Bleed or Bruise Easily
Peculiar Tastes or Smells
Strong Thirst (hot or cold drinks)
Sudden Energy Drop
Poor Sleep Habits
[]
[]
[]
[]
[]
[]
[]
Tremors
Poor Balance
Cravings
Weight Gain
Alcoholism
Tetanus Shot
Frequent cold/flu
[]
[]
[]
[]
[]
Open sore
Acne
Corns
Warts
Psoriasis
[]
[]
[]
[]
[]
Recent moles
Loss of Hair
Hives
Nail Problems
Dry skin
[]
[]
[]
[]
[]
[]
[]
Migraines
Eye Pain
Color Blindness
Earaches
Spots in front of eyes
Recurrent Sore Throats
Facial Pain
[]
[]
[]
[]
[]
[]
Coronary Heart Disease
Difficulty in Breathing
Hardening of Arteries
Phlebitis
Blood Clots
Cold hands/feet
Head, Eyes, Ears, Nose and Throat
[] Dizziness/Vertigo
[] Concussions
[] Poor Vision
[] Eye Strain
[] Cataracts
[] Night Blindness
[] Ringing in ears
[] Blurry Vision
[] Sinus Problems
[] Poor Hearing
[] Grinding Teeth
[] Nose Bleeds
[] Nasal Congestion
[] Hoarseness
[] Headaches
Cardiovascular
[] High Blood Pressure
[] Low Blood Pressure
[] Palpitations
[] Irregular Heartbeat
[] Mitral Stenosis
[] Mitral Prolapse
Respiratory
[] Cough
[] Bronchitis
[] Difficulty breathing lying down
[] Emphysema
Gastrointestinal
[] Nausea
[]
[]
[]
[]
[]
[]
Myocarditis
Pneumatic Heart Disease
Chest Pain
Varicose Veins
Swelling of Hands/Feet
Fainting
[] Coughing Blood
[] Pneumonia
[] Asthma
[] Pain w/ deep breath
[] Production of Phlegm
[] Pleurisy
[] Constipation
[] Diarrhea
[]
[]
[]
[]
[]
Vomiting
Bad Breath
Abdominal Pain or Cramps
Indigestion
Ulcer
[]
[]
[]
[]
[]
Gas
Blood in Stools
Rectal Pain
Chronic Laxative Use
Colitis
[]
[]
[]
[]
Genitourinary
[] Bed Wetting
[] Kidney Infections / Stones
[] Genital Herpes
[] Cystitis
[]
[]
[]
[]
Blood in Urine
Painful Urination
Venereal Disease
Incontinence
[] Frequent Urination
[] Bladder Infections
[] Prostate Problems
Pregnancy and Gynecology
[ ] Number of Pregnancies
[ ] Number of Abortions
[ ] Number of Births
[ ] Number of Miscarriages
[] Use of Birth Control
[] Clots
[] Hot Flash/Night Sweats
[] Osteoporosis
Belching
Black Stools
Hemorrhoids
Acid Reflux
[ ] Age at 1st Menstruation
____ Time between Menstruation
____ Duration of Menstruation
____ First Date of Last Menstruation
[] Irregular Periods
[] Endometriosis
[] Frequent changes in emotion
[]
[]
[]
[]
[]
[]
[] Muscle Pains
[] Muscle Weakness
[] Shoulder Pain
[] Knee Pain
[] Foot/Ankle Pain
[] Hip Pain
Neuropsychological
[] Seizures
[] Areas of Numbness
[] Concussion
[] Bad Temper
[] Difficulty Concentrating
[]
[]
[]
[]
[]
[]
[]
[]
Infection
[] Measles
[] Rheumatic Fever
[] Malaria
[] Small Pox
[] Mumps
[] Tuberculosis
[] Chicken Pox
Musculoskeletal
[] Neck Pain
[] Back Pain
[] Hand/Wrist Pain
Dizziness
Lack of Coordination
Depression
Easily susceptible to stress
Unusual Character (heavy/light)
Vaginal Sores
Vaginal Discharge
Breast Lumps
Painful Periods/Cramps
Uterine Fibroids
Loss of Balance
Poor Memory
Anxiety
ADD
[] Whopping Cough
[] Typhoid Fever
[] Scarlet Fever
Other
Are you allergic to any of the following? If yes, please specify)
( ) Medicine
( ) Food
( ) Herbs
( ) Others
Do you have or are you any of the following?
( ) Pacemaker
( ) Electric Implants
( ) Metal Implants
( ) Severe Bleeding Disorders
( ) Pregnant
( ) HIV Positive
( ) Hepatitis A/B/C
Social History
No
Coffee ___
Tea
___
Alcohol ___
Tobacco ___
Other ___
Yes
___
___
___
___
___
When Started
___________
___________
___________
___________
___________
When Stopped
____________
____________
____________
____________
____________
Family History (please include the relation)
[] Migraines
____________________
[] Heart Disease
____________________
[] Allergies
____________________
[] Asthma
____________________
[] Arthritis
____________________
[] Diabetes
____________________
[] Glaucoma
____________________
[]
[]
[]
[]
[]
[]
[]
Amount
______
______
______
______
______
Stroke
High Blood Pressure
Mental Illness
Gall Stones
Cancer
Thyroid Disease
Epilepsy
____________________
____________________
____________________
____________________
____________________
____________________
____________________
Comments
Please tell us of any other problems you would like to discuss:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________