Download Overall energy (Lung, Kidney function)

127 W. Bell St., Sequim, WA 98382
HEALTH HISTORY QUESTIONNAIRE
All information is confidential.
I. General Patient Information
Date: _____/_____/_____
Name: Mr./Mrs./Ms._______________________________________________________________________________
Address: __________________________________City, State, Zip Code:___________________________________
Home Phone: (
Cell Phone: (
)__________________________Work Phone: (
)______________________________________
)__________________________ Email Address: _________________________________________
Age: ______ Date of Birth: ______/______/______ Time of Birth (If known)______________________________
Guardian (if under 18): ____________________________________________________________________________
Emergency Contact (name and phone #):
____________________________________________________________
Gender: M F Height: ____’____” Weight: ________lbs. Occupation:________________________________
How did you hear about us?________________________________________________________________________
Major Health Concerns, in order of significance, to you today:
1. ___________________________________________ 2. ________________________________________________
3.
___________________________________________ 4. _______________________________________________
What are Your Treatment Goals? (Please rank in order 1, 2, 3)
____ Temporary relief of symptoms/pain management
____ Eliminate root/cause of my health concern (If possible)
____ Maintain care (Periodic balancing/tune-up to maintain current level of health)
II. Patient Medical History
Significant childhood health issues?_________________________________________________________________
Hospital
Visits/Stays:______________________________________________________________________________________
Recent tests: (please indicate test results and date below)
Physical
Cholesterol
Prostate
HIV/STD
Pap smear
Mammography
Blood (which?)
Other:____________________
Test Results and Date:_______________________________________________________________________
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Check any you have been diagnosed for in the past:

Diabetes
Allergies
Glaucoma
Rheumatic Fever
Heart Disease
CVA (stroke)
Vein condition
Thyroid disorder
Asthma
Pneumonia
Tuberculosis
Emphysema
Jaundice
Gonorrhea
Mumps
Bleeding tendency
Syphilis
Measles
Chicken pox
Nervous disorder
Meningitis
HIV
Polio
Mononucleosis
Epilepsy
High fever
Hepatitis
Multiple Sclerosis
Paralysis
Cancer
Migraines
High blood pressure
 Other lung illnesses
Any liver illnesses Any heart illnesses Any kidney illnesses

Other:____________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Immunizations:_____________________________________________________________________________________________
Surgeries:__________________________________________________________________________________________________
III. Patient’s Pain Profile
The pain quality is:
Sharp
Burning
Aching
Cramping
Dull
Moving
Fixed
Other:________________
What reduces the pain?
Pressure
Cold
Heat
Exercise
Other_________
What increases the pain?
Pressure
Cold
Heat
Other:_______________________________
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Please check the boxes that currently, within the past 3-6 months, pertain to you:
Overall Temperature (Yin & Yang): The following symptoms indicate imbalance of Yin and Yang
in your body. Yin is the cool, moist, nourishing aspect of the body. Yang is the hot, dry, invigorating
aspect of the body.
Cold hands Cold fingers Cold toes Cold feet Sweaty hands Sweaty feet Hot
body temperature (sensation) Cold body temperature (sensation) Afternoon flushes
Night sweats Heat in the hands, feet, and chest Hot flashes (Any time) Thirsty
Perspire easily Lack of perspiration Take water to bed
Overall energy (Lung, Kidney function):
Shortness of breath Difficulty keeping eyes open in the daytime General weakness
Easily catch colds Low energy Feel worse after exercise
Heart function: The following symptoms are indicators of heart imbalance. The heart governs the
blood & blood vessels, manifests in the complexion, rules emotions, affects speech, taste, and controls
perspiration.
Palpitations Anxiety Sores on the tip of the tongue Restlessness
Mental confusion Chest pain traveling to shoulder Frequent dreams
Wake unrefreshed Drink coffee (# of cups per week: _______)
Lung function: The following symptoms are indicators of lung imbalance. The lungs govern
breathing, control the movement of energy, control the immune system, regulate water passages,
manifest in the skin and open to the nose, throat, and sinuses.
Nasal Discharge (Color: _________________) Cough Nose Bleeds Sinus Congestion
Dry mouth Dry throat Dry Nose Dry Skin
Allergies (To what? ________________________) Alternating fever and chills Sneezing
Headache (Location: ________________________) Overall achy feeling in the body
Stiff neck Stiff shoulders Sore throat Difficulty breathing
Smoke cigarettes (# of cigarettes per day: _______) Sadness Melancholy
Spleen function: The following symptoms are indicators of spleen malfunction. The spleen assists in
breaking food down into usable nutrients and then transports those nutrients throughout the body, keeps
the blood in the blood vessels, governs the muscles, manifests in the lips and holds the organs up in the
body.
Low appetite Abrupt weight gain Abrupt weight loss Abdominal bloating
Abdominal gas Gurgling noise in the stomach Fatigue after eating
Prolapsed organs (previously diagnosed, which organ? __________________________)
Easily bruised Hemorrhoids Pensive Over-thinking Worry
Spleen, Stomach, Large Intestine, Small Intestine function:
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Loose stools Constipated Incomplete bowel movement Diarrhea
Blood in stools Mucous in stools Undigested food in stools



Dampness trapped in the body: The following symptoms indicate of “dampness,” which refers to
fluids that are not metabolized effectively and cause health problems in the body. Dampness is considered
pathologic fluid.
General sensation of heaviness in the body Mental heaviness Mental sluggishness
Mental fogginess Swollen hands Swollen feet Swollen joints Chest congestion
Nausea Snoring
Stomach function: The following symptoms are indicators of stomach malfunction. The stomach
controls the breakdown of food and nutrients, descends the energy and is the origin of the body’s fluids.
Burning sensation after eating Large appetite Bad breath Mouth (canker) sores
Bleeding, swollen or painful gums Heartburn Acid regurgitation Ulcer (diagnosed)
Belching Hiccoughs Stomach pain Vomiting

Liver, Gall Bladder function: The following symptoms indicate liver imbalance. The liver stores
blood, ensures the smooth flow of qi and blood throughout the body, nourishes the tendons and ligaments,
manifests in the nails and opens to the eyes. The gall bladder stores bile, which breaks down fats.
Alternating diarrhea and constipation Chest pain Tight sensation in the chest
Bitter taste in the mouth Anger easily Frustration Depression Irritability
Frequently unable to adapt to stress What causes the stress? _________________________
Skin rashes Headache at the top of the head Tingling sensation Numbness
Muscle spasms Muscle twitching Muscle cramping Dizziness Seizures
Convulsions Lump in the throat Neck tension Limited Range-of-Motion, Neck
Shoulder tension Limited Range-of-Motion, Shoulder
Drink alcohol (What type?_______________________, How much per week?________)
Recreational drugs (Which? ____________________, How much per week? ________)
Hip pain High-pitched ringing in the ears Gall stones (past or current)
Sexually transmitted disease (Which? _______________________)
Eyes (Liver function):
Itchy Bloodshot Hot Dry Watery GrittySee floating spots in eyes
Blurry vision Decreased night vision Near-sighted Far-sighted

Kidney, Urinary Bladder function: The following symptoms are indicators of kidney or urinary
bladder imbalance. The kidney and adrenal system rule birth/development/growth/reproduction,
produces marrow, nourish the brain, control bones, govern water, open to the ears, manifest in hair,
control the ureter/spermatic duct and lower section of the large intestine. The urinary bladder stores and
eliminates impure fluids.
Frequent cavities Easily broken bones Sore knees Weak knees
Cold sensation in the knees Low back pain Memory problems Excessive hair loss
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Urination:
Color: Normal color Dark yellow Clear Reddish Cloudy
Amount: Scanty Profuse
Other: Strong odor Burning Painful Discharge Difficult Urgent Frequent

Libido (Sex Drive): Normal High Low
MEN ONLY: (answers indicate overall body imbalance)
Swollen testes Testicular pain Impotence Premature ejaculation
Feeling of coldness or numbness in external genitalia Other______________________________

WOMEN ONLY: (answers indicate overall body imbalance)
Regular menstrual cycle? Y N Might you currently be pregnant?Y N
Number of children:________ Number of pregnancies:________ Age of first menstruation:______
Age of menopause (if applicable):________ Average number of days of flow:________
Average number of days of entire cycle:________
Vaginal discharge (Unusual color, odor, consistency) Bleeding or spotting between periods
Do you experience any of the following pre-menstrual syndromes?
nausea vomiting water retention breast swelling food cravings headaches
migraines breast tenderness depression irritability anxiety
other emotions:___________________________
dull pain, where?_________________________ sharp pain, where?____________________
Please fill in the following menstrual chart:
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Color (bright red, pale, brown, rust,
dark, purple, other)
Flow (normal, heavy, light)
Pain/cramps (location, dull, sharp, other)
Clots (large, small, black, purple, red,
other)
Vomiting (check if yes)
Nausea (check if yes)
Other
Other
Comments:_______________________________________________________________________________
Patient Signature:_______________________________________
Acupuncturist Signature:_________________________________
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