Initial Health History

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

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? Yes / No

3. 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? 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:

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.

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

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:

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