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HEALTH HISTORY QUESTIONNAIRE

Please allow up to 30 minutes to complete this form.

Please enter your first name.

Please enter your last name.

Please enter your address.

Please enter your city.

Please enter your state.

Please enter your zip code.

Please enter your phone number.

Please enter your cell phone number.

Please enter a valid email address.

Please enter your place of birth.

/ / Please enter your date of birth.

Please enter your height.

Please enter your weight.

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Have you been given a diagnosis by a physician or specialist for the problem?
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Have you tried acupuncture before?
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Have you tried Chinese Herbs before?
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PAST MEDICAL HISTORY

Please check all that apply.
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Family Medical History
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LIFESTYLE

Do you follow a regular exercise program?
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Please describe your average daily diet:
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Do you experience any craving or binges?
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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.)

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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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Please indicate if you are presently taking medications.

Please indicate if you are taking vitamins and/or supplements.

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.

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SKIN AND HAIR
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MUSCULOSKELETAL
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Any replacement surgery?
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HEAD, EYES, EARS, NOSE, THROAT
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Have you been diagnosed with thyroid problems?
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Are you taking thyroid medication?
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CARDIOVASCULAR
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RESPIRATORY AND IMMUNE SYSTEM
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GASTROINTESTINAL
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Is it
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GENITOURINARY
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WOMEN AND GYNECOLOGY, REPRODUCTIVE AND SEXUAL HEALTH
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Do you practice birth control?
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Any history of breast cancer?
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History of breast cancer in your family?
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Any history of
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MEN’S REPRODUCTIVE AND SEXUAL HEALTH
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NEUROLOGICAL
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Have you been diagnosed with any neurological disease?
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EMOTIONAL AND PSYCHOLOGICAL
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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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SPIRITUAL HEALTH

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COMMENTS
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