Birthdate (Required) Sex (Required) Current Health Concerns
Please list your health concerns. Begin with the most important to address today.
Classify your health concern as 1= Minor; 2 = Moderate; 3 = Fairly severe and getting worse; 4 = Serious
To what extent do these problems interfere with or impact your daily activities (work, sleep, play)? What type of service(s) do you desire?
Please list some of the most significant events in your life, beginning with the most recent, (such as marriage/divorce, birth of child, career changes, personal or professional recognition, periods of grief, accidents) General Information Have you had acupuncture before? Do you bruise easily? Do you bleed for a long time from a cut? Do you have a tendency to faint? Are you nervous about needles? Are you generally very tired? Do you have high blood pressure? Do you have a pacemaker? Do you have hepatitis, cancer or HIV? Have you recently traveled outside US? Have you ever been treated for emotional problems? Have you ever considered or attempted suicide? Women: Are you pregnant? Women: Are you perimenopausal? Women: Have you reached menopause? Personal Health Habits Smoker Alcohol Recreational Drugs Coffee Regular Exercise Stress: What do you currently find most stressful? Daily Diet: Please describe an average daily diet: Do you fall a sleep easily? Do you wake up often? Are you happy with your level of energy? Hospitalization/Accidents Please list any hospitalizations, surgery, serious injuries, and recent dental work with a short description and date. Current & Former Conditions
Do You Have Any Of The Following? Check any of the following areas of complaint that you are experiencing now or have experienced in the past 3 months.
Medications/Vitamins Please list all your medications (including sleeping pills, birth control) and non-prescription drugs (such as Aspirin, antacids, laxatives, antihistamines) that you take on a regular basis. Please list all vitamin supplements you are taking on a regular basis and their dosage. Family History Place a check for those diseases one or both of your parents had; place a plus + for any diseases your siblings have; you may place both a check and plus if necessary. Please note the degree of severity of your Please note the greatest degree of severity problem now on a scale of 1-10 (with 10 being the highest): Please note the greatest degree of severity of your problem within this past week now on a scale of 1-10 (with 10 being the highest): Thank you for your time spent with this form. I appreciate your time spent, but also your willingness to share things that maybe are not normally asked.