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HEALTH HISTORY QUESTIONNAIRE

Please allow up to 30 minutes to complete this form.

Date(*)
Please enter the date.

First Name(*)
Please enter your first name.

Last Name(*)
Please enter your last name.

Address(*)
Please enter your address.

City(*)
Please enter your city.

State/Province(*)
Please enter your state.

Zip Code(*)
Please enter your zip code.

Home Phone(*)
Please enter your phone number.

Cell Number
Please enter your cell phone number.

Email Address(*)
Please enter a valid email address.

Place of Birth(*)
Please enter your place of birth.

Date of Birth(*)
/ / Please enter your date of birth.

Height(*)
Please enter your height.

Weight(*)
Please enter your weight.

WHAT IS YOUR MAIN PROBLEM (or reason you are seeking Chinese medicine)?(*)
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To what extent does this problem affect your daily activities (work, sleep, eating, etc.)?
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How long since you first noticed symptoms?
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Have you been given a diagnosis by a physician or specialist for the problem?
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If so, what is it?
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Have you tried acupuncture before?
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Have you tried Chinese Herbs before?
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What other kinds of treatment or therapy have you tried for your problem?
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What kind of results have you had from any of the modalities that you have tried?
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What seems to make your problem or condition better or worse?
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PAST MEDICAL HISTORY

Please check all that apply.
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Other relevant medical history or treatment (such as chemotherapy, radiation), when and how long?
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Family Medical History
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LIFESTYLE

Do you follow a regular exercise program?
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How many times a week?
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Please describe
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Please describe your average daily diet:
Breakfast
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Lunch
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Dinner
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Snacks
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Do you experience any craving or binges?
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If so, for what type of food or “treat”?
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How often?
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What are the triggers?
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Are you currently using any of the following?
(Please indicate daily amount, frequency and type.
Indicate if you have a past history and the date when you stopped.)

Cigarette smoking
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Marijuana or any other type of “recreational” drug
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Medicinal drugs
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Alcoholic beverages
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Soft drinks or energy drinks
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Coffee or caffeinated drinks
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Sugar, honey and sweets (including fruit juice)
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Do you have or have you ever suffered from an eating disorder
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Are you or have you ever been under treatment for substance abuse?
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In your own estimation, do you have a history of or present problem with substance abuse and/or addiction?
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Are you presently taking any medication? Which ones?(*)
Please indicate if you are presently taking medications.

Are you taking any vitamins or supplements? Which ones? (*)
Please indicate if you are taking vitamins and/or supplements.

Are you taking any herbal or homeopathic supplements? Which ones?(*)
Please indicate if you are taking any herbal or homeopathic supplements.

 

GENERAL HEALTH

Check any conditions you have experienced within the last three months. Indicate the length of time that you have had this condition or noticed the problem
Please check all that apply.(*)
Please select all that apply.

Other unusual or abnormal conditions in your general health
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SKIN AND HAIR
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Additional Hair and Skin Information
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MUSCULOSKELETAL
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Any other joint or bone problems?
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Any difficulty walking, sitting or standing?
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Any replacement surgery?
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If so, which part of the body?
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How long ago?
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HEAD, EYES, EARS, NOSE, THROAT
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Headache and Migraine Additional Information
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Any other head or neck problems
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Have you been diagnosed with thyroid problems?
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How long ago?
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Which type?
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Are you taking thyroid medication?
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Which thyroid medications?
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CARDIOVASCULAR
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Blood Pressure and Edema additional info
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Other heart or blood vessel problems
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RESPIRATORY AND IMMUNE SYSTEM
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Allergy and Phlegm Additional Information
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Any other lung problems
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GASTROINTESTINAL
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Any other problem with stomach or intestines?
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How often do you have a bowel movement?
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Is it
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What is the usual color?
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GENITOURINARY
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Night urination additional information
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Any other genital abnormality or urinary problems?
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WOMEN AND GYNECOLOGY, REPRODUCTIVE AND SEXUAL HEALTH
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Please describe in more detail relevant information above.
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Age at first menses
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Age at menopause and how long ago?
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Number of pregnancies
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Any chance you might be pregnant now?
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Time between cycles: (Indicate days or months)
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Duration of bleeding in days
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First day of last menses
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Do you practice birth control?
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If so, what type and for how long ?
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Any other gynecological issues or history of gynecological problems
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Any history of breast cancer?
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If yes, when and what type of treatment did you or are you receiving?
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History of breast cancer in your family?
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Who in your family?
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Any history of
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MEN’S REPRODUCTIVE AND SEXUAL HEALTH
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How long have you been impotent?
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How many children do you have?
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Do you or have you ever used Viagra? If yes, how long?
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NEUROLOGICAL
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Where are you numb?
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Have you been diagnosed with any neurological disease?
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Any other neuro-cerebral problem? Please describe
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EMOTIONAL AND PSYCHOLOGICAL
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Are you following any type of psychotherapy? (If yes, what type)
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Have you ever contemplated suicide?
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Attempted to commit suicide?
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Have you ever been diagnosed with any of the follow psychiatric disorders?
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Any other significant emotional issue or trauma?
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SPIRITUAL HEALTH

Do you follow any kind of spiritual practice? Please describe if you feel comfortable doing so
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How do you view health and disease from a spiritual point of view?
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COMMENTS
Please list any other problems that you would like to discuss or adresss or any information you would like to add:
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