HEALTH HISTORY — Courtland Acupuncture

Thank you for filling the following form the best you can. It will provide us with useful information to understand your unique situation. Please do not hit the Return key, as it will submit the form before you are finished. Once you have reached the bottom of this page, you will see the Submit button, and can click on it.

GENERAL INFORMATION

Address

Marital Status

Email

Emergency Contact: Phone #, Name, Relationship to Patient

Family Doctor: Name, City, Phone #

Main Occupation(s)

How did you hear about us?

Have you had Acupuncture before. If yes, with whom?

Have you had Shiatsu massage before. If yes, with whom?

Thank you for filling the form below. It will help us understand better what your health issues are about, applying the hoslistic approach of Acupuncture and Traditional Chinese Medicine

CURRENT HEALTH CONCERNS

Main Issue you would like help with (Chief Complaint):

When did it start? What caused it?

Indicate the level of pain / discomfort if any (0 = no pain / discomfort, 10 = worst you ever had). Describe what you feel. What makes it better, what makes it worse? Did you get a diagnosis, are your receiving treatments, which ones? How does it affect your life? What have you done to help it so far?

Other concerns you would like help with?

MEDICAL HISTORY

List all medical diagnoses you have (eg. diabetes, hypothyroid, depression, cancer, etc):

INJURIES, SURGERIES, HOSPITALIZATIONS: please list with dates

Have you had traumatic experiences:

MEDICATIONS: please list current prescriptions and what they are for, since when (eg. Prozac, antidepressant, since 2004 etc.)

SUPPLEMENTS AND NATURAL REMEDIES: please list

Family Health History: please list major illnesses in your family (eg father: diabetes, depression. Uncle: Parkinson, prostate cancer etc)

HEALTH AND LIFESTYLE

Weight and height

Work Hours Per Week

Number of days of vacation each year

Sleep Hours Per Night

Exercise Type and Frequency

Special Diet or Food Sensitivity

Caffeine/Smoke/Alcohol/Substance Use & Frequency

What do you typically have 1- for breakfast, 2- for lunch, 3- for dinner:

What snacks do you typically have, and when?

CONDITIONS AND SYMPTOMS YOU HAVE OR YOU HAD BEFORE

Musculo-Skeletal / Body Overview

List all the parts of your body where you are experiencing pain or numbness or paralysis (eg low back pain, right shoulder pain, left leg numbness etc)

Feel free to add to this

Please list the scars you have (where, why)

Cancer (where, survivor, recent diagnosis, undergoing treatment)

Feel free to add to this

WOMEN'S HEALTH

Age first menstruation?

Age of menopause (if applicable)

Number of children

Number of miscarriages, abortions?

Length of cycle, ie Number of days between day #1 of a period and day #1 of the next period (eg. 28 to 30)

Number of days each period lasts (eg. 5)

Are you using birth control, method, since when?

List symptoms you typically have when you menstruate (eg back pain, cramps, clot, heavy bleeding, irregular periods, mood issues etc)

Feel free to add about gynecology (eg fibroids, STD, low libido, fertility issue, other etc)

Are you taking hormonal therapy, since when?

Other information regarding women's health?

Would you like to add anything else?

Thank you very much! You can now hit the Submit button. This information will remain strictly confidential.