Page 1 of 5 PATIENT INFORMATION NAME ADDRESS TELEPHONE (Street) (City, State, ZIP) P Check your preferred contact number. q Home q Office q Mobile EMAIL SSN AGE HEIGHT WEIGHT GENDER q Male q Female DATE OF BIRTH OCCUPATION & EDUCATION MARITAL STATUS DATE OF FIRST VISIT q Single q Married q Life Partner q Divorced q Widowed REFERRED BY Have you tried the following treatments? q Acupuncture q Herbal Medicine q Acupressure (tui na) q Craniosacral EMERGENCY CONTACT PRIMARY PHYSICIAN S INFORMATION Name: Telephone: Address: Name: Telephone: Address: Medications, supplements, or herbs you are currently taking: Date of last physical exam:
Page 2 of 5 MAJOR OR PRIMARY COMPLAINT 1. 2. 3. When did you first notice this problem? How long have you had this problem? What makes it better? What makes it worse? On a scale of 1 to 10, with 10 being the worst, how would you rate the pain? Have you experienced this problem in the past? q Allergies q Hepatitis ( A / B / C / D ) q Seizures q Venereal disease (STIs) q Significant trauma q Reactions to vaccinations q Cancer MEDICAL HISTORY q High blood pressure q High cholesterol q Rheumatic fever q Thyroid disease q Childhood illnesses q Diabetes q Heart disease q Birth trauma q Ulcers q HIV or AIDS q Headache q Other (please specify): FAMILY MEDICAL HISTORY (select all that apply and indicate which relative) q Cancer q Rheumatic fever q Heart disease q Tuberculosis q High blood pressure q Seizures q Hepatitis q Diabetes q Emotional disorders q Other conditions (specify) LIFESTYLE (select all that apply and indicate frequency) q Coffee q Black tea q Caffeinated beverages q Alcohol q Tobacco q Recreational drugs q Exercise
Page 3 of 5 ALLERGIES, HOSPITALIZATION, INJURIES, OR AUTOIMMUNE DISEASES Allergies? Cardiac pacemaker? Major surgeries? Hospitalized? Major accidents, esp. to head? Replaced/added parts in body? Body parts or organs removed? Lyme or autoimmune disease? History of psychiatric treatment? q Poor appetite q Large appetite q Strong thirst q Food cravings q Weight loss q Weight gain q Cold feet and hands q Tremors GENERAL HEALTH AND WELL- BEING q Poor balance q Poor coordination q Night sweats q Insomnia q Disturbed sleep q Bruise or bleed easily q Catch colds easily q Chills q Fevers q Sweats easily q Fatigue q Sudden energy loss q Anemia q Rashes q Ulcerations q Psoriasis q Acne q Itching q Redness SKIN AND HAIR q Hair loss q Recent moles q Dandruff q Eczema q Hives q Dry skin q Neurodermatitis q Warts q Shingles q Dizziness q Headaches q Migraines q Facial pain or numbness q Trigeminal neuralgia q Bell s Palsy q TMJ or jaw clicking q Floaters q Eye pain q Blurred vision HEAD, EYES, EARS, NOSE, AND THROAT q Night blindness q Dry eyes or redness q Glaucoma q Cataracts q Tinnitus q Decreased hearing q Ear infection q Nosebleeds q Sinusitis q Hay fever / allergies q Change in smell q Sore throat q Hoarseness q Difficulty swallowing q Change in taste q Oral ulcers q Toothache q Bleeding gums
Page 4 of 5 q Palpitations q Irregular heart beat q Coronary heart disease q Chest pain / tightness CARDIOVASCULAR q Poor circulation q High blood pressure q Low blood pressure q Swelling of hands / feet q Blood clots q Chronic cough q Coughing blood q Coughing phlegm q Nasal congestion q Shortness of breath RESPIRATORY q Difficulty breathing q Difficulty breathing when lying down q Pneumonia q Asthma q Frequent/chronic colds q Bronchitis q Flu q Nausea q Vomiting q Diarrhea q Constipation q Gas q Bloating q Belching q Abdominal pain / Cramps GASTROINTESTINAL q Chronic gastritis q Ulcers q Indigestion q Heartburn or acid reflux q Lack of appetite q Excessive hunger q Rectal pain q Bloody or black stools q Hemorrhoids q Bad breath q Frequent laxative use q Gallstones q Jaundice q Cirrhosis q Frequent urination q Painful urination q Urgent urination q Decrease in urine flow q Increase in urine flow UROGENITAL q Waking at night to urinate q Incontinence q Bladder infection q Blood in urine q Impotence q Kidney stones q Genital sores q Other (please specify): q Neck pain q Back pain q Knee pain q Foot or ankle pain q Shoulder pain q Hip pain q Hand or wrist pain MUSCULOSKELETAL q Finger pain q Leg cramps q Rib pain q Cervical spondylopathy q Carpal tunnel syndrome q Tennis elbow q Acute lumbar sprain q Chronic lumbar strain q Sprained ankle q Sciatica q Muscle weakness q Scoliosis
Page 5 of 5 q Seizures q Epilepsy q Dizziness q Loss of balance q Numbness q Poor memory q Lack of coordination NEUROPSYCHOLOGICAL q Concussion q Depression q Anxiety q Bad temper q Stress q Attempted suicide q History of psychiatric treatment q Insomnia q Stroke or TIA q Hemiplegia q Alcoholism q Schizophrenia METABOLISM, ENDOCRINE, AND IMMUNE q Diabetes q Gout q High cholesterol q Hyperthyroidism q Hypothyroidism q Simple obesity q Rheumatic arthritis q Arthritis q Lupus q Fibromyalgia q Chronic fatigue syndrome MALE REPRODUCTIVE SYSTEM AND GENITALIA q Pain or itching of genitalia q Genital lesions or discharge q Lumps in testicles q Impotence q Enlarged prostate or prostatitis FEMALE REPRODUCTIVE SYSTEM AND GYNECOLOGICAL q Painful menses q No menses q Scanty menstrual flow q Irregular menses q Premenstrual syndrome q Menstrual odor q Vaginal discharge q Vaginal dryness q Pelvic inflammatory disease q Abnormal pap smear q Fibroids q Breast lumps or swelling q Endometriosis q Ovarian Cysts q STD q Urinary tract infection q Hot flashes q Decreased sex drive q Vulvodynia q Vomiting during pregnancy q Infertility q Polycystic ovarian syndrome AGE AT COLOR (First period) (Menopause) # Days (Period flow) (Length of cycle) q Brown q Light red/pink QUANTITY q Heavy q Moderate q Light q Dark red q Bright red CLOTS q Big q Small q None PMS SYMPTOMS # PREGNANCIES # LIVE BIRTHS # MISCARRIAGES OR ABORTIONS CURRENTLY SEXUALLY ACTIVE q Yes q No CONTRACEPTION (if any) RELEVANT PREGNANCY HISTORY