Fill out Health History Questionnaire

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HEALTH HISTORY QUESTIONNAIRE

Please allow up to 30 minutes to complete this form.

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?

YesNo Invalid Input

If so, what is it?

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Have you tried acupuncture before?

YesNo Invalid Input

Have you tried Chinese Herbs before?

YesNo Invalid Input

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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LIFESTYLE

Do you follow a regular exercise program?

YesNo Invalid Input

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?

YesNo Invalid Input

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

anorexiabulimiacompulsive overeating Invalid Input

Are you or have you ever been under treatment for substance abuse?

YesNo Invalid Input

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.

HEALTH HISTORY QUESTIONNAIRE

Please allow up to 30 minutes to complete this form.

PAST MEDICAL HISTORY

LIFESTYLE

GENERAL HEALTH

SPIRITUAL HEALTH

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