Wellness Acupucture & Natural Medicine Inc.

Comprehensive Health History Form

(Please print)

Name: Date of Birth: Today’s Date:

REASONS FOR TODAY’S VISIT:

What makes it better?

What makes it worse?

What treatment(s) have you had for this condition?

Howbad is your pain? 1 2 3 4 5 6 7 8 9 10

No pain Unbearable pain

Describe your current pain/symptoms: [ ] Shooting [ ] Throbbing [ ] Dull [ ]

Sharp/Stabbing
[ ] Burning [ ] Soreness [ ] Numb [ ] Tingling [ ] Other:
__________________________

Have you had Acupuncture before? [ ] Never [ ] Yes; When ________ What for
_______________
What are your goals with Acupuncture treatment?
___________________________________________

Are you currently pregnant? [ ] Yes [ ] No

Are you currently wearing a pace maker? [ ] Yes [ ] No

CURRENT MEDICATIONS (include supplements and any non-prescribed products):

Medication Strength (mg.) Doses/Day

ALLERGIES: [ ] None [ ] Yes List: _______________________________________________

(Continued on the back)
Sound Acupuncture & Herbs

FEMALES:
Date of last menses: ___________________ Age at first menses: ___________________
Days between menses (cycle): ___________ Length of menses: ____________________
Number of Pregnancy: _____ Miscarriages / terminations: _____ Number of live
births: _____
Age at menopause: ____________________ Current contraception: ____________________

Do you now, or have you had problems with:

Now Past Never Now Past Never

1. Fatigue (ongoing) 25. Heartburn
2. Weight Loss (unplanned) 25. Stomach pain, ulcers
3. Anxiety, Depression 27. Nausea, Vomiting
4. Memory Loss 28. Diarrhea
5. Anemia 29. Hepatitis, Jaundice
6. Stroke 30. Constipation
7. Headache, Dizziness 31. Blood in stools
8. Seizure, Blackouts 32. Kidney disease, stone
9. Chest pains 33. Blood in urine
10. Heart Disease 34. Control of urine, Incontinence
11. High Blood Pressure 35. Sexually transmitted disease
12. High Cholesterol 36. Joint pain, swelling
13. Irregular Heartbeat 37. Gout
14. Ankle Swelling 38. Diabetes
15. Phlebitis (blood clots in legs) 39. Thyroid disease
16. Eyes (Vision) 40. Excessive thirst, urination
17. Ears (Hearing) 41. Decreased sex drive
18. Nose (Sinuses) 42. Menstrual problems [Females]
19. Hoarseness 43. Abnormal Pap smear [Females]
20. Throat pain, trouble swallowing 44. Breast lump, pain
21. Hay fever, Allergies 45. Erections [Males]
22. Asthma, Wheezing 46. Cancer
23. Cough 47. Tuberculosis
24. Shortness of Breath 48. Skin problems, mole changes
Family History:

Has anyone in your family had: [ ] Diabetes; who ____________ [ ] Heart attack;
who ____________
[ ] High blood pressure; who ___________ [ ] Cancer; who ____________ ; where;
______________

Are you currently smoking? [ ] Yes [ ] No How many packs per day?
____________________
Do you drink alcohol? [ ] Yes [ ] No Average number of drinks per week:
_____________
Are you exercising regularly? [ ] Yes [ ] No Describe:
___________________________________