Patient Information

  Name
 
  Gender
  Male Female
  Place of Birth
 
  DoB
 
  Date
 
  Age
 
  Height (Å°):
 
  Weight
 
  SSN
 

 
  Phone
 
  Cell
 
  Current Address
 
  City
 
  State / Zip
  /
  Email (Required)
 
  Business Address
 
  City
 
  State / Zip
  /
  Phone
 
  Occupation
 
  Marital Status
 Single Married Life Partner
Divorced Widowed
  In Case of Emergency Notify
 
  How did you hear of this office?
 
  Have you ever before tried acupuncture or Chinese herbal medicine
  Yes No
  Please list any medications and/or supplements you are currently taking.
  What are the main health problems for which you are seeking treatment?
  Please rate the extent to which your current complaint affects your daily life  
  Please rate your commitment to resolving this problem  
  What other forms of treatment have you sought?  

  Past Medical History

  Allergies

  Yes No
  Cancer
  Yes No
  Diabetes
  Yes No
  Hepatitis
  Yes No
  High Blood Pressure
  Yes No
  Heart Disease
  Yes No
  Seizures
  Yes No
  Surgeries
  Yes No
  Rheumatic Fever
  Yes No
  Venereal Disease
  Yes No
  Thyroid Disease
  Yes No
  Birth Trauma
  Yes No
  Vaccinations
  Yes No
  Childhood Illnesses
  Yes No
  Significant Trauma
  Yes No
  Medications
  Yes No
  Accidents
  Yes No
  Others
 

  Family Medical History
  Cancer
  Yes No
   High Blood Pressure
  Yes No
  Hepatitis
  Yes No
   Rheumatic Fever
  Yes No
  Infectious Disease
  Yes No
   Diabetes
  Yes No
  Heart Disease
  Yes No
   Seizures
  Yes No
  Emotional Disorder
  Yes No
   Tuberculosis
  Yes No
  Other
  

  Lifestyle
  Coffee
  Yes No
   Black Tea
  Yes No
  Tobacco
  Yes No
   Alcohol
  Yes No
  Caffeinated Beverages
  Yes No
   Recreational Drug
  Yes No
  Exercise
  Yes No
  

  General Health
  Poor Appetite
  Yes No
   Weight Gain
  Yes No
  Disturbed Sleep
  Yes No
   Fatigue
  Yes No
  Poor Coordination
  Yes No
   Insomnia
  Yes No
  Cold Hands and Feet
  Yes No
   Tremors
  Yes No
  Night Sweats
  Yes No
   Fevers
  Yes No
  Large Appetite
  Yes No
   Sweat Easily
  Yes No
  Localized Weakness
  Yes No
   Chills
  Yes No
  Strong Thirst
  Yes No
   Weight Loss
  Yes No
  Poor Balance
  Yes No
   Cravings
  Yes No
  Bruise/Bleed Easily
  Yes No
   Sudden Energy Droop
  Yes No
  Soft/Brittle Nails
  Yes No
   Cold Abdomen
  Yes No
  Catch Colds Easily
  Yes No
    
  Other (±âŸ)
  

  Skin & Hair
  Rashes
  Yes No
   Itching
  Yes No
  Dandruff
  Yes No
   Ulcerations
  Yes No
  Redness
  Yes No
   Eczema
  Yes No
  Psoriasis
  Yes No
   Hair Loss
  Yes No
  Hives
  Yes No
   Pimples
  Yes No
  Recent Moles
  Yes No
  Other  

  Head, Eyes, Ears, Nose, Throat
  Dizziness
  Yes No
   Eye Pain
  Yes No
  Blurred Vision
  Yes No
   Floaters
  Yes No
  Spots In Eyes
  Yes No
   Night Blindness
  Yes No
  Ringing in Ears
  Yes No
   Poor Hearing
  Yes No
  Earaches
  Yes No
   Headaches
  Yes No
  Migraines
  Yes No
   Recurrent Sore Throats
  Yes No
  Sores on Lips/Tongue
  Yes No
   Facial Pain
  Yes No
  Dry Mouth/Throat
  Yes No
   Bleeding Gums
  Yes No
  Nosebleeds
  Yes No
   Jaw Clicking
  Yes No
  Difficulty breathing when lying down
  Yes No
  Other  

  Cardiovascular
  Dizziness
  Yes No
   Chest Pain
  Yes No
  Low Blood Pressure
  Yes No
   High Blood Pressure
  Yes No
  Fainting
  Yes No
   Cold Hands/Feet
  Yes No
  Cold Hands/Feet
  Yes No
   Palpitations
  Yes No
  Bloods Clots
  Yes No
   Difficulty Breathing
  Yes No
  Irregular Heart Beat
  Yes No
   Swelling of Hands/Feet
  Yes No
  Other
  

  Respiratory
  Cough
  Yes No
   Pneumonia
  Yes No
  Asthma
  Yes No
   Coughing
  Yes No
  Shortness of Breath
  Yes No
   Bronchitis
  Yes No
  Nasal Congestion
  Yes No
   Coughing Phlegm 
  Yes No
  Difficulty Breathing when lying down
  Yes No
   Pain With Deep Breath
  Yes No
  Other
 

  Gastrointestinal
  Nausea
  Yes No
   Vomiting
  Yes No
  Diarrhea
  Yes No
   Constipation
  Yes No
  Gas
  Yes No
   Bloathing
  Yes No
  Chronic Laxative
  Yes No
   Heartburn/Reflux
  Yes No
  Abdominal Pain/Cramps
  Yes No
   Indigestion
  Yes No
  Retention of Food in Stomach
  Yes No
   Lack of Appetite
  Yes No
  Excessive Appetite
  Yes No
   Rectal Pain
  Yes No
  Black Stools
  Yes No
   Hemorrhoids
  Yes No
  Belching
  Yes No
   Bad Breath
  Yes No
  Sensitive Abdomen
  Yes No
  Other
 

  Genito-Urinary
  Pain On Urination
  Yes No
   Frequent Urination
  Yes No
  Blood in Urine
  Yes No
   Urgency to Urinate
  Yes No
  Unable to Hold Urine
  Yes No
   Kidney Stones
  Yes No
  Decrease in Urine Flow
  Yes No
   Impotence
  Yes No
  Sores on Genitals
  Yes No
   Waking at Night to Urine
  Yes No
  Other
 

  Reproductive/Gynecological
  Age of 1st Period
 
  Age at menopause
 
  Pregnancies
  
  Live Births
 
  Premature Births
  
  Miscarriages/Abortions
 
  days between periods
  
  days of flow
  
  Color of blood
  
  Clots
  Yes No
  Painful Menses
  Yes No
  Irregular Menses
  Yes No
  Premenstrual Symptoms
  Yes No
  Strong Menstrual Odor
  Yes No
  Vaginal Discharge
  Yes No
  Vaginal Oder
  Yes No
   Vaginal Dryness
  Yes No
  Fibroids
  Yes No
   Endometriosis
  Yes No
  Breast Lumps/Swellings
  Yes No
  Ovarian Cysts
  Yes No   Decreased Sex Drive
  Yes No
  Sexually Transmitted Disease
  Yes No
  Urinary Tract Infection
   Yes No   Hot Flashes
  Yes No
  Positive Mammogram/Pap Smear
  Yes No
  Other
  

  Skeletal Muscle
  Neck Pain
  Yes No
   Back Pain
  Yes No
  Knee Pain
  Yes No
   Muscle Pain
  Yes No
  Foot/Ankle Pain
  Yes No
   Shoulder Pain
  Yes No
  Hip Pain
  Yes No
   Sciatica
  Yes No
  Hand /Wrist Pain
  Yes No
   Muscle Weakness
  Yes No
  Other Joint/Bone Problems
 

  Neuro-Psychological
  Seizures
  Yes No
   Loss of Balance
  Yes No
  Dizziness
  Yes No
   Anxiety
  Yes No
  Areas of Numbness
  Yes No
   Poor Memory
  Yes No
  Lack of Coordination
  Yes No
   Concussion
  Yes No
  Depression
  Yes No
   Bad Temper