Comprehensive Health History Form

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: ___________________________________