Fill out Health History Questionnaire

Page 1 of 5

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)?(*)

Invalid Input

To what extent does this problem affect your daily activities (work, sleep, eating, etc.)?

Invalid Input

How long since you first noticed symptoms?

Invalid Input

Have you been given a diagnosis by a physician or specialist for the problem?

YesNo Invalid Input

If so, what is it?

Invalid Input

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?

Invalid Input

What kind of results have you had from any of the modalities that you have tried?

Invalid Input

What seems to make your problem or condition better or worse?

Invalid Input

LIFESTYLE

Do you follow a regular exercise program?

YesNo Invalid Input

How many times a week?

Invalid Input

Please describe

Invalid Input

Please describe your average daily diet:

Breakfast

Invalid Input

Lunch

Invalid Input

Dinner

Invalid Input

Snacks

Invalid Input

Do you experience any craving or binges?

YesNo Invalid Input

If so, for what type of food or “treat”?

Invalid Input

How often?

Invalid Input

What are the triggers?

Invalid Input

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

Invalid Input

Marijuana or any other type of “recreational” drug

Invalid Input

Medicinal drugs

Invalid Input

Alcoholic beverages

Invalid Input

Soft drinks or energy drinks

Invalid Input

Coffee or caffeinated drinks

Invalid Input

Sugar, honey and sweets (including fruit juice)

Invalid Input

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?

Invalid Input

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

Contact

Technical Support

Testimonials

Dr. Papin's Consultations

User Menu