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Initial Health History
Name:
Email Address:
I. Goals
What would you most like to acheive through your work at the CHW Acupuncture Center?
1.
2.
3.
4.
5.
II. Major Symptoms
Please list in order of importance what symptoms are of concern to you.
(most concerning to least, duration of the symptom)
1.
2.
3.
4.
Are you experiencing pain/discomfort in any part of the body?
Yes
/
No
For Women:
(Men, please skip to "
Medical History
")
1.
Are you pregnant now?
Yes
/
No
/
Unsure
2. Indicate number of occurences:
Live Births
Pregnancies
Miscarriages
Abortions
3. Age:
First period
Menopause (if applicable)
4. Date:
Last Pap Smear
/
Last Mammogram
/
5.
Any History of an Abnormal Pap Smear?
Yes
/
No
If so, what / when?
6.
Is your menses cycle regular?
Yes
/
No
a) Average number of days of flow
b) The flow is:
Your menses cycle flow is?
Normal
/
Heavy
/
Light
c) The color is:
Your menses cycle color is?
Normal
/
Dark
/
Purple
/
Light Brown
/
Brown
7. Do you have the following menstruation related signs/symptoms?
Difficulty with Orgasm
Cramps
PMS
Pain with Intercourse
Nausea
Bleeding between Periods
Blood Clots
Breast Distention
Vaginal Discharge
Heavy Vaginal discharge between periods
III. Medical History
Please check all that apply
Date Diagnosed
Diabetes
/
/
High Cholesterol
/
/
High Blood Pressure
/
/
Low Blood Pressure
/
/
Thyroid Disease
/
/
Seizures
/
/
Cancer
/
/
Hepatitis
/
/
HIV
/
/
Others
/
/
IV. Surgical History
Date:
Date:
Date:
IX. Social History
1. How much per day do you use of the following?
a) Coffee, tea, soft drinks:
b) Alcohol:
c) Cigarettes, cigars, other tobacco:
d) Other drugs:
2. Have you ever had a problem with
alcohol
or
alcoholism
?
Have you ever had a problem with alcohol or alcoholism?
Yes
/
No
3. Have you ever had a problem with
dependency
on other drugs?
Have you ever had a problem with dependency on other drugs?
Yes
/
No
4. If yes which and when?
5. Do you have a known history of any exposure to
toxic
substances?
Do you have a known history of any exposure to toxic substances?
Yes
/
No
6. If so, please list which and when you first noticed symptoms?
7. In the past year, how many days have been significantly affected by your health?
8. How many days did you feel generally poor?
9. How many times were you in the hospital?
10. Please describe your current exercise regimen:
Hours per week:
Activities:
No Excersize
11.How many hours of sleep do you usually get per night during the week?
12. a)
Do you awake feeling rested?
Yes
/
No
b)
Do you feel you sleep well at night?
Yes
/
No
13. Who would you describe as your source of primary social support? (relationship to you)
X. Other Information
1. Please list and briefly describe the most significant events in your life:
a)
b)
c)
d)
2.
Have you been treated for emotional issues?
Yes
/
No
3.
Have you ever considered or attempted suicide?
Yes
/
No
4.
Do you have any other neurological or psychological problem?
Yes
/
No
5. Please provide us with any other information that you think is relevant for us to know:
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?
Yes
/
No
b) If yes, how would you describe the diet? (ie Vegetarian, Vegan, Low Carb, etc.)
2. What do you eat on a "typical" day?
a) Breakfast:
b) Lunch:
c) Dinner:
d) Snacks:
e) Foods you tend to crave:
f) Foods you dislike:
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
Other:
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:
Code:
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