Axis Acupuncture & Chinese Herbal Medicine
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Axis Acupuncture & Chinese Herbal Medicine 263 Concord Ave. 4 Cambridge, MA 02138 4 617.791.3348 Jennifer@axisacupuncture.com Health History Information Please take the time to fill out this questionnaire. This information about your health history is important for your treatment. If you have any questions, please don’t hesitate to call and ask. This information is absolutely confidential. Thank you! Name___________________________________________________________________ Date ____________________________ Address: ____________________________________________ City:__________________________________________________ State:____________________ Zip:______________ Home Phone:___________________________________________________ Mobile Phone:_______________________________ Work Phone:__________________________________________________ May I contact you at work?________ E-Mail:___________________________________ Occupation: ___________________ Date of Birth:_________________________ Age:________________ Referred By: _____________________________________ Emergency Contact:_____________________________________ Phone: Main Issue for Seeking Help: (please include symptoms, duration, western diagnosis, etc) _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________(please use back side of form if you need more room) _____________________________________________ What makes your condition better? (resting, moving, eating, heat, cold, crying) ______________________________________ ________________________________________________________________________________________ __________________ What makes your condition worse? (stress, fatigue, sitting in one place for too long, damp days, heat, cold, exercise, resting, eating) ________________________________________________________________________________________ ____________ Significant Trauma: (physical or emotional) ____________________________________________________________________ ________________________________________________________________________________________ __________________ Surgeries, Hospitalizations: __________________________________________________________________________________ ________________________________________________________________________________________ __________________ Allergies: (environmental, food, drugs, etc) _____________________________________________________________________ Any Western medical diagnoses?______________________________________________________________________________ Medications: (names, dosages, why are you taking them?) ________________________________________________________ ________________________________________________________________________________________ __________________ _______________________________________________________________________(please attach separate page if necessary) Vitamins, supplements, herbs:________________________________________________________________________________ ________________________________________________________________________________________ __________________ Exercise: Days per week____________________ Type of Activities _________________________________________________ Do you follow a specific diet? (Vegetarian, Vegan, etc)___________________________________________________________ Caffeinated Drinks: How many per day ___________________________ What drinks? ________________________________ Alcoholic drinks per week ____________________ Family Medical History Please check any condition that applies to your Put an F (father), M (mother), S (sister), B (brother), GM (grandmother), GF (grandfather) next to choice. immediate family. Diabetes ___ Seizures ___ Heart Disease ___ High Blood Pressure ___ Allergies ___ Asthma ___ Other_______________________________________ Stroke ___ Cancer ___ Please check if you have had any of these symptoms listed below in the last year Please make an X if you have had any of these symptoms NOW Skin and Hair Rashes Face flushing Eczema/Psoriasis Weak or ridged nails Change in skin/hair texture Acne Dry skin Loss of hair Itching Fungal Infection Head, Eyes, Ears, Nose and Throat Dizziness Eye Pressure Grinding teeth Ringing in ears Jaw clicks/locks Migraines Headaches Eye pain Poor night vision Nose bleeds Sores on lips/tongue Blurred vision Earaches Spots in front of eyes Sinus congestion Cardiovascular Chest pain or pressure Varicose/spider veins rest Fainting Cold hands/feet Swelling of hands/feet Blood clots pressure Spontaneous sweating Palpitations at High blood Respiratory Cough/Wheezing Tight sensation in chest Difficulty breathing when lying down Shortness of breath Difficult inhale/exhale Asthma Production of phlegm… what color? Gastrointestinal Nausea Gas Acid reflux/GERD Disease Bloating/Edema Vomiting Belching Bad breath Diarrhea Blood in stool Hemorrhoids Constipation Poor appetite IBS/Crohn’s Significant thirst Abdominal pain/cramps Excessive appetite Frequent urination Blood in urine Burning urination Urgent urination Scanty urine flow Genito-Urinary Decreased libido Unable to hold urine Copious flow Impotence Pain on urination Premature ejaculation urination… How often?_____ Urinary tract infection Dribbling after urination Prostatitis Night Gynecological/Reproductive Difficult/Painful intercourse Ovarian cysts menses__________________ Vaginal dryness Endometriosis Vaginal sores Uterine Fibroids menstrual period____________ Age of first Date of last Vaginal discharge pregnancies_______________ Infertility pregancies_________ Irregular menstruation births________________ Fibrocystic breast tissue Number of Polycystic Ovarian Disease Number of ectopic PMS Painful menstruation miscarriages_______________ Do you practice birth control?________ abortions_________________ What type?__________________________________ Number of live Number of Number of Musculoskeletal Neck pain Shoulder pain Knee pain Sprains/Strains pain Hip pain Muscle pain Soreness/weakness in lower body (back, knee, Hand/wrist pain Sciatica Carpal Tunnel Foot/ankle Muscle weakness hip, ankle, foot Tendonitis Rotator Cuff Areas of numbness Concussion Bad temper/irritable Manic Depression Depression Easily susceptible Neuropsychological Seizures Loss of balance Nervousness Poor memory Anxiety/Panic attacks to stress ADD/ADHD Have you ever been treated for emotional problems? Have you ever considered or attempted suicide? Have you ever been treated for substance abuse? Yes No Yes Yes No No Comments: Are there any other issues you would like to discuss with me? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ______________________________________________________ Thank you for taking the time to fill this out!
