Conscious Health & Wellness - Miriam Pineles, L.Ac., Dipl. OM - 347-878-9619

Initial Health History



I. Goals
What would you most like to acheive through your work at the CHW Acupuncture Center?

II. Major Symptoms
Please list in order of importance what symptoms are of concern to you.
(most concerning to least, duration of the symptom)
Are you experiencing pain/discomfort in any part of the body? /
For Women: (Men, please skip to "Medical History")
1. Are you pregnant now? / /
2. Indicate number of occurences:
    
3. Age:
4. Date: / /
5. Any History of an Abnormal Pap Smear? /
    
6. Is your menses cycle regular? /
    
    b) The flow is: / /
    c) The color is: / / / /
7. Do you have the following menstruation related signs/symptoms?

III. Medical History
Please check all that apply Date Diagnosed
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /

IV. Surgical History
Date:
Date:
Date:

IX. Social History
1. How much per day do you use of the following?
2. Have you ever had a problem with alcohol or alcoholism? /
3. Have you ever had a problem with dependency on other drugs? /
5. Do you have a known history of any exposure to toxic substances? /

    

    
10. Please describe your current exercise regimen:
      
12. a) Do you awake feeling rested? /
      b) Do you feel you sleep well at night? /

      

X. Other Information
1. Please list and briefly describe the most significant events in your life:
    
    
    
    
2. Have you been treated for emotional issues? /
3. Have you ever considered or attempted suicide? /
4. Do you have any other neurological or psychological problem? /
    

V. Family History
Please check all that apply to the family member with that condition.
Condition Mother Father Sibling Maternal
Grandparent
Paternal
Grandparent
Heart disease
Cancer
Hypertension
Stroke
Asthma
Allergies
Migraines
Depression
Other mental illness
Substance abuse
Osteoporosis
Diabetes
Glaucoma

VI. Medications / Supplements
Medications you are currently taking (please include prescription medicine, supplement, herbal supplements and over the counter medicines you take on a regular basis, along with dosages and brands if known)

Allergies (to medications, chemicals or foods):

VIII. Nutrition
1. a) Do you follow a special diet? /
    
    

HEALTH:

CHECK ALL THAT APPLY

GENERAL
Past Current Condition
Poor appetite
Excessive appetite
Insomnia
Fatigue
Fevers
Night sweats
Sweat easily
Chills
Localized weakness
Poor coordination
Bleed or bruise easily
Catch cold easily
Change in appetite
Strong thirst

SKIN & HAIR
Past Current Condition
Rashes
Hives
Itching
Eczema
Pimples
Dryness
Tumors, lumps

HEAD & NECK
Past Current Condition
Dizziness
Fainting
Neck stiffness
Enlarged lymph glands
Headaches
Concussions
Other:

EARS
Past Current Condition
Infection
Ringing
Decreased hearing
Other:

EYES
Past Current Condition
Blurred vision
Visual changes
Poor night vision
Spots
Cataracts
Glasses / contacts
Eye inflammation
Other:

NOSE, THROAT, MOUTH
Past Current Condition
Nose bleeds
Sinus infections
Hay fever or allergies
Rccurring sore throats
Grinding teeth
Difficulty swallowing

CARDIOVASCULAR
Past Current Condition
High blood pressure
Low blood pressure
Blood clots
Palpitations
Phlebitis
Chest pain
Irregular heart beat
Cold hands / feet
Fainting
Difficult breathing
Swelling of hands / feet
Other:

RESPIRATORY
Past Current Condition
Asthma
Bronchitis
Frequent colds
Chronic obstructive
Pulmonary disease
Pneumonia
Cough
Coughing blood
Production of phlegm
Other:
Refresh

GASTRO-INTESTINAL
Past Current Condition
Nausea
Vomiting
Diarrhea
Belching
Blood in stools/black
Stools
Bad breath
Rectal pain
Hemorrhoids
Constipation
Pain or cramps
Indigestion
Gall bladder disorder
Gas
Other:

GENITO-URINARY
Past Current Condition
Kidney stones
Pain or urination
Frequent urination
Blood in urine
Urgency to urinate
Unable to hold urine
Other:

FEMALE
Past Current Condition
Frequent urinary tract infections
Frequent vaginal infections
Pain / itching of genitalia
Genital lesions / discharge
Pelvic inflammatory disease
Abnormal pap smear
Irregular menstrual periods
Painful menstrual periods
Premenstrual syndrome
Abnormal bleeding
Menopausal syndrome
Breast lumps
Hot flashes
Other:

NEUROLOGICAL
Past Current Condition
Seizures
Tremors
Numbness/tingling of limbs
Concussion
Pain
Paralysis
Other:

PSYCHOLOGICAL
Past Current Condition
Depression
Anxiety / stress
Irritability
Treated for emotional or
Psychological problems
Other:

INFECTION SCREENING
Past Current Condition
HIV
TB
Hepatitis
Gonorrhea
Chlamydia
Syphilis
Genital warts
Herpes: oral
Herpes: genital

MUSCULAR-SKELETAL
Past Current Condition
Stiff neck / shoulders
Low back pain
Back pain
Muscle spasm, twitching, cramps
Sore, cold or weak knees
Joint pain

Licensed Acupuncturist, Board Certified in Chinese Medicine