Acupuncture Health Center

1303 Astor Street, Suite 101 (360) 715-1824 Office Scott Palia, L.Ac
Bellingham, WA 98225 (360) 715-1648 Fax Bree Racine, L.Ac

Day One: Health History Questionnaire

Patient’s Name: Age : Date :
(Physical Exam) Bp: (L or R Arm) _____ SYS_____ DIA _____ Pulse (Before Treatment) Weight: ______________
Bp: (L or R Arm) _____ SYS_____ DIA _____ Pulse (After Treatment) Temperature: _______ (F)

Main Complaint(s):
1. Complaint 2. Complaint 3. Any Other Complaint(s)
e.g.

Onset: How Long? Onset: How Long? A

Previous Ex: How Happen? Prev. Ex: How Happen?

B

Misc. Notes:

Review of Systems Familial History

PE WNL ABNL Reason Who? What problem? Are they receiving care?

Constitution o Yes o No
Head/Mental o Yes o No
HA’s o Yes o No
Eyes o Yes o No
Ears o Yes o No
Nose o Yes o No
Throat o Yes o No
Chest o Yes o No
Heart o Yes o No
Respiratory o Yes o No
Stomach o Yes o No
Abdomen o Yes o No
Skin o Yes o No
L.Ac’s Signature _________________________________ TX: _______ ( _____ of ______ ) or TX/HC: ________ of _________

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 Acupuncture Health Center
1303 Astor Street, Suite 101 (360) 715-1824 Office Scott Palia, L.Ac
Bellingham, WA 98225 (360) 715-1648 Fax Bree Racine, L.Ac

Has your sleep been disrupted in any of the following ways ?

1. Do you have trouble falling asleep ? o Yes o No

2. Is your sleep restful (do you wake refreshed) ? o Yes o No

3. Do you awaken in the middle of the night as a result of your problem ? o Yes o No

4. Do you wake earlier than you would normally ? o Yes o No

1. Are you discourage with your current health status ? o Yes o No

2. If you are NOT discouraged, what adjective best describes how you view your health ? _________________________

3. How do you health problems affect your relationship(s) ?

Work ? _________________________________________________________________________________________

Family / Friends ? ________________________________________________________________________________

4. What hobbies or activities would you resume if it weren’t for your health issues ? ______________________________

____________________________________________________________________________________________________

5. Would you agree that your health seems to be having a negative affect on your life ? o Yes o No

6. How much younger would you feel if your health concerns could be erased away ? ____________________________

7. If your health problems aren’t resolved, and they have been going on for _________________months/years, what will

be the result if they continue for another _____________________ months/years ?

8. On a scale of 1-10, with ten being the highest, how committed are you in wanting to rid yourself of these

problems and feeling great ? ___________________________________________________________________________

9. Assuming that we could help you with your condition, is there anything that would prevent you from

following through with the treatment plan ? o Yes o No

10. Are there any other barriers to your commitment, e.g. time, transportation, other ? Please specify :

____________________________________________________________________________________________________

TX : _____(_____of_____)

L.Ac’s Signature : _____________________________________________________________________

TX/HC : (_____of_____)

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