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Dr. David M. Thayer, DC, FIAMA, Dipl. Ac. Board Certified Acupuncture, Auriculotherapy, and Chiropractic PATIENT VITAL INTAKE [HQ] HEALTH QUESTIONAIRE __________________________________________________ Patient Name ________/________/________ Birthdate ___________ Age _______________________ Home Phone ___________________ Height __________________ Weight _______________________ Work Phone _______________________ Cell Phone Complaints: How long has it been occurring? Treatment/Palliative action (What makes it feel better)? _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Please list all surgeries, traumas, medications, and allergies. Give dates, age of occurrences, or years as best as you can remember. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Family Medical History O Obesity O Diabetes O Stroke O Heart Disease O Seizures O High Blood Pressure O Other Diseases / Cancer (explain below) Your Habits O O O O O O Cigarettes Marijuana Unprescribed Drugs Coffee Bitter Chocolate Sugar O Alcohol Drinks Per Week: _____ O Occasionally O Often Frequency: Please explain: ______________________________________________________________________ O Tea O Carbonated Beverages Cups/Glasses/Cans per day: _____________ O Sweet Chocolate O Artificial Sweetener O Salt Please explain any cravings or any other items you feel are important that we know: _______________________________________________________________________________________________________________________ General Issues O O O O O O O Poor Appetite O Heavy Appetite Insomnia O Fatigue Cold Hands O Cold Feet Fevers O Chills Cravings O Localized Weakness Sudden Energy Drops (Time?) ____________ Strong Thirsts (cold/hot drinks) ____________ O O O O O O O Poor Sleep O Heavy Sleep Tremors O Vertigo Cold Back O Cold Abdomen Night Sweats O Sweat Easily Poor Coordination O Changes in Appetite Peculiar Tastes/Smells (explain?) _____________________________ Bleed / Bruise Easily (where?) _______________________________ Skin / Hair O Rashes O Ulcerations O Eczema O Pimples O Change in Hair/Skin Texture O Hives O Dandruff O Purpua O Itching O Loss of Hair O Other hair/skin issues (explain below) Head / Eyes / Ears / Nose / Throat O Dizziness O Concussions O Migraines O Wear Corrective Lenses O Eye Strain O Eye Pain O Poor Vision O Night Blindness O Color Blindness O Cataracts O Blurry Vision O Earaches O Ringing in Ears O Poor Hearing O Nose Bleeds O Sinus Problems O Mucus O Dry Throat O Dry Mouth O Copious Saliva O Teeth Problems O Jaw Clicks O Grinding Teeth O Facial Pain O Gum Problems O Spots in Eyes O Recurrent Sore Throats (how many times per month?)_____________ O Sores on Lips or Tongue O Headaches (where and when?) O Other Head / Neck Problems ______________________________________________________________________________ PATIENT VITAL INTAKE [HQ] HEALTH QUESTIONAIRE Cardiovascular O High Blood Pressure O Dizziness O Blood Clots O Low Blood Pressure O Fainting O Phlebitis O Chest Pain O Cold Hands / Feet O Difficulty Breathing O Irregular Heartbeat O Swelling in Hands / Feet O Other Respiratory O Cough O Coughing Blood O Asthma O Bronchitis O Pneumonia O Difficulty in Breathing When Lying Down O Tight Chest O Production of phlegm: Frequency? (daily, hourly, etc.) _______________ What Color? _______________ Gastrointestinal O Nausea O Gas O Bad Breath O Constipation O Pain or Cramps O O O O O Gastro-Urinary O Pain at Urination O Unable to Hold Urine O Wake Up to Urinate O Frequent Urination O Blood in Urine O Kidney Stones O Venereal Disease How Often? ______/night; times: _______________ Vomiting O Diarrhea Belching O Black Stool Rectal Pain O Hemorrhoids Bloody Stools O Sensitive Abdomen Laxative Use: ____times/wk. type: ____________ Pregnancy and Gynecology O # of Pregnancies: _______ O Number of Births: _______ O Age at First Menses: _____ O Period Length: _______ days O Flow (describe below) O Clots O Vaginal Discharge O Vaginal Sores O Birth Control: Type: _____________ Duration: ___________ Musculoskeletal O Neck Pain O Muscle Pains O Other Joint or Bone Problems? O O O O O BOWEL MOVEMENTS Frequency: _____________ Color: _____________ Odor: _____________ Texture/Form: _____________ O Urgency to Urinate O Impotency O Other Gastro-Urinary Problems Premature Births: _______ O Miscarriages: ____________ Duration: ______________ O Irregular Periods: _________ Last PAP: _____________ O Last Menses: ____________ Breast Lumps O Menopause: _____________ Changes in Body / Psyche prior to Menstruation? O Back Pain (where?) Neuropsychological O Seizures O Areas of Numbness O Poor Memory O Depression O Anxiety O Bad Temper O Treated for emotional problems (explain below) O Other neurological or psychological problems? (explain below) O Joint Pains (where?) O Concussion O Easily Stressed O Considered/Attempted Suicide Classical PREFERENCE Season Taste Climate Time of Day Temperature MOST LIKED LEAST LIKED Body Type Color Tone Yin/Yang Firm/Weak Hot/Cold Surface/Interior I certify that the above accurately describes my symptoms as of the date of this form: ________________________________________________________________ ________________ Signature of Patient Date