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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:_______________________________________________________________________ 1 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:_______________________________ 2 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: 3 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 GrittySee 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 4 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:_________________________________ 5