Health History Questionnaire

Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All of your answers will be held absolutely confidential. Some questions may seem unrelated to your main complaint—this is because acupuncture looks at the whole person. How your different systems are working and interacting may help in the diagnosis and aid in treatment of the main problem.

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
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

Recreational Drugs
Regular Exercise

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?


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.


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 enter a number from 1 to 10.
Please enter a number from 1 to 10.

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.