Acupuncture Health History Form

Please complete the following form. This information will help your practitioner to assess your needs before any hands-on work is done and to provide you with the highest quality of care. Any information that is provided will be kept confidential.

First Name *

Last Name *

Address *

City *

State *

Zip *

Best number to reach you *

Do you wish to fill out the complete form now?
Yes No

Email *

Date of Birth *

Age

Height

Weight

Work Phone

Occupation

Full Name of Emergency Contact

Phone Number of Emergency Contact

Referred By

Family Physician

Medical Insurance Carrier

Medical Insurance Carrier Phone

Have you tried acupuncture or Chinese herbal medicine before?
Yes No

What is your main health concern?

To what extent does this problem affect your daily activities? Please explain.

How long has it been since you first noticed any symptoms?

Have you been given a diagnosis for the problem by your family physician?
Yes No

What is the diagnosis?

What kinds of treatment or therapy have you tried?

Past Medical History: Please indicate whether you have any of the following conditions. Add any comments that may further clarify your condition.

Condition:

Comments:

Allergies

Cancer

Diabetes

Hepatitis

High Blood Pressure

Heart Disease

Seizures

Rheumatic Fever

Venereal Disease

Thyroid Disease

Birth Trauma
(i.e. prolonged labor)

Other Trauma

Other Condition

Family Medical History: Please indicate whether your family has had any of the following conditions. Add any comments that may further clarify the condition.

Condition:

Comments:

Allergies

Asthma

Cancer

Diabetes

High Blood Pressure

Heart Disease

Seizures

Stroke

Other Condition

Occupational Stress Factors:
(i.e. physical, chemical, etc.)

Do you exercise?
Yes No

How Often?

What Type?

Other Activities:
(i.e. walking to work)

Please describe your average daily diet.

Please check any of the following habits that apply. Indicate how much and how often you use them.

Habit:

Comments:

Cigarette Smoking

Coffee, Tea or Cola

Alcoholic Beverages

List medications taken within the last two months.

Describe any use of drugs for non-medical purposes.

Please check any of the following conditions you have experienced within the last three months. Indicate the length of time you have had any of these conditions.

General

Condition:

Comments:

Poor Appetite

Insomnia

Disturbed Sleep

Localized Weakness

Cravings

Strong Thirst

Weight Gain

Weight Loss

Changes in Appetite

Excessive Sweating

Tremors

Bleed or Bruise Easily

Night Sweats

Fever

Chills

Sudden Energy Drop

Poor Balance

Skin and Hair

Condition:

Comments:

Rashes

Ulcerations

Hives

Itching

Eczema

Pimples

Dandruff

Hair Loss

Recent Moles

Texture Change (Hair/Skin)

Head, Eyes, Ears, Nose, Throat

Condition:

Comments:

Concussions

Migraines

Glasses

Spots in Front the of Eyes

Eye Pain

Poor Vision

Night Blindness

Color Blindness

Cataracts

Blurry Vision

Earaches

Ringing in Ears

Poor Hearing

Eye Strain

Sinus Problems

Recurrent Sore Throat

Nose Bleeds

Grinding Teeth

Sores on Lips or Tongue

Facial Pain

Teeth Problems

Headaches

Jaw Clicks

Cardiovascular

Condition:

Comments:

Dizziness

Low Blood Pressure

Chest Pain

Irregular Heartbeat

High Blood Pressure

Fainting

Cold Hands or Feet

Swelling of Hands

Swelling of Feet

Blood Clots

Difficulty Breathing

Phlebitis

Respiratory

Condition:

Comments:

Cough

Coughing Up Blood

Asthma

Bronchitis

Pain with Deep Inhalation

Pneumonia

Difficulty Breathing when Lying Down

Excessive Phlegm

Gastrointestinal

Condition:

Comments:

Nausea

Vomiting

Diarrhea

Constipation

Gas

Belching

Black Stool

Blood in Stool

Indigestion

Bad Breath

Rectal Pain

Hemorrhoids

Abdominal Pain or Cramps

Chronic Laxative Use

Genitourinary

Condition:

Comments:

Pain on Urination

Frequent Urination

Blood in Urine

Urgency to Urinate

Unable to Hold Urine

Kidney Stones

Decrease in Flow

Impotence

Sores on Genitals

Do you wake up at night to urinate?
Yes No

How Often?

Particular Color of Urine:

Reproductive and Gynecologic

Condition:

Comments:

Premenstrual Changes

Menstrual Clots

Painful Menses

Unusual Menses

Heavy Menstrual Flow

Light Menstrual Flow

Irregular Menses

Premature Births

Miscarriages

Abortions

Age of First Menses:

Age at Menopause:

Number of Pregnancies:

Time Between Cycles:

Duration of Bleeding:

First Day of Last Menses:

Do you practice birth control?
Yes No

What type of birth control?

How long have you used birth control?

Musculoskeletal

Condition:

Comments:

Neck Pain

Muscle Pains

Knee Pain

Back Pain

Muscle Weakness

Foot/Ankle Pains

Hand/Wrist Pains

Shoulder Pains

Hip Pain

Neuropsychological

Condition:

Comments:

Seizures

Dizziness

Loss of Balance

Areas of Numbness

Poor Memory

Lack of Coordination

Concussion

Depression

Anxiety

Bad Temper

Easily Susceptible to Stress

Have you ever been treated for emotional problems?
Yes No

Have you ever considered or attempted suicide?
Yes No

Do you have any other neurological or psychological problems?
Yes No

Please explain any other problems you would like to discuss.

How did you hear about us?

Would you like to receive email notifications regarding new services, discounts, promotions and more?
Yes No

Check all that apply.

Last Minute Specials
Newsletter
Promotions and Discounts
Seminars

Consent for Care: It is my choice to receive acupuncture . I am aware of the benefits and risks of acupuncture and give my consent for acupuncture. I acknowledge that acupuncture is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I Agree.

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2285 Massachusetts Ave Cambridge, MA 02140

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Phone: (617)354.3082
Fax: (617) 354.3085
Email: info@sollievo.org

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Acupuncture Health History Form

Sollievo - Massage and Bodywork