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Nashua Acupuncture
& Chinese Herbal Medicine
3E Taggart Drive Nashua, NH 03060 603-598-1515 |
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Health History Questionaire |
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Please take the time to fill out this questionaire carefully. All information provided is
kept confidential. If there is anything you would like to bring to our attention which is not
on this form, please note it in the 'comments' section. Thank you.
| Date
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| Name |
Home Phone |
Work Phone |
| Street |
Age |
Date of Birth |
| City |
Occupation |
Height |
| State |
Zip |
Weight |
| Family Physician |
Emergency Contact |
Referred by |
| Insurance |
Marital status |
E-Mail Address |
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Have you ever been treated by acupuncture or Oriental medicine before? Yes..... No.....
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What would you like to work on?
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When did this first start?
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Does this interfere with daily activities, work, sleep, sex?
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Do have a western diagnosis?
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What treatments have you tried?
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Past Medical History
Significant Illnesses (please circle)
| Cancer | Diabetes | Hepatits | High Blood Pressure | Rheumatic Fever |
| Thyroid Disease | Seizures | Venereal Disease | Other: |
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| Surgeries |
| Significant Trauma (auto accidents, falls, etc.) |
| Allergies (drugs, chemicals, foods) |
Family Medical History
| Cancer | Diabetes | Hepatits | High Blood Pressure |
| Stroke |
Asthma | Allergies | Other: |
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Medicines taken within the last 2 months?
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Occupational stress?
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Do you have a regular exercise program?
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Are you/have you been on a restricted diet?
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Please describe your average daily diet:
| Morning: | | | | | Afternoon: | | | | | Evening: |
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How much water do you drink per day? |
| Do you smoke? If yes, how much? |
| How much caffienated coffee, tea, or cola do you drink per week? |
| Please describe any use of drugs for non-medical purposes. |
Please check if you have had in the last three months:
__ Fevers
__ Sweat easily
__ Bleed or bruise easily
__ Peculiar taste or smells
__ Sudden energy drop
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__ Poor sleeping
__ Chills
__ Weight loss
__ Strong thirst
__ Fatigue
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__ Night sweats
__ Cravings
__ Change in appetite
__ Weight gain
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Skin & Hair
__ Rashes
__ Itching
__ Dandruff
__ Change in hair or skin texture
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__ Ulcerations
__ Eczema
__ loss of hair
__ Hives
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__ Pimples
__ Recent moles
__ Any other hair or skin problems?
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Head, eyes, ears, nose and throat
__ Dizziness
__ Glasses
__ Poor Vision
__ Cataracts
__ Ringing in ears
__ Sinus problems
__ Grinding teeth
__ Teeth problems
__ Any other head or neck problems?
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__ Concussions
__ Eye strain
__ Night blindness
__ Blurry vision
__ Poor hearing
__ Nose bleeds
__ Facial pain
__ Jaw clicks
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__ Migraines
__ Eye pain
__ Color blindness
__ Earaches
__ Spots in front of eyes
__ Recurrent sore throats
__ Sores on lips or tongue
__ Headaches
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Cardiovascular
__ High Blood pressure
__ Irregular heartbeat
__ Cold hands and feet
__ Blood clots
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__ Low blood pressure
__ Swelling of hands
__ Phlebitis
__ Difficulty in breathing
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__ Chest pain
__ Fainting
__ Swelling of feet
__ Any other cardiovascular problems?
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Respiratory
__ Cough
__ Bronchitis
__ Pneumonia
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__ Coughing blood
__ Production of phlegm
__ Asthma
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__ Difficulty in breathing while lying down
__ Pain with a deep breath
__ Any other lung issues
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Gastrointestinal
__ Nausea
__ Constipation
__ Black stools
__ Bad Breath
__ Abdominal pain or cramps
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__ Vomiting
__ Gas
__ Blood in stools
__ Rectal pain
__ Chronic laxitive use
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__ Diarrhea
__ Belching
__ Indigestion
__ Hemorrhoids
__ Poor appetite
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Genito-Urinary
__ Pain upon urination
__ Urgency to urinate
__ Decrease in urine flow
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__ Do you wake up to urinate?
__ Unable to hold urine
__ Impotence
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__ Blood in urine
__ Kidney stones
__ Sores on genitals
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Musculoskeletal
__ Neck pain
__ Back pain
__ Hand/wrist pain
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__ Muscle pain
__ Muscle weakness
__ Shoulder pain
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__ Knee pain
__ Foot/ankle pains
__ Hip pain
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Reproductive and gynecologic
__ Breast lumps
__ Irregular periods
__ Menstrual pain
__ Menstrual clots
Number of days period lasts___
Number of days between periods___
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__ Vaginal discharge
__ Unusual periods
__ Spotting between periods
__ Menopause: age___
Age of first menses___
Birth control? Yes___ No ___
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# of pregnancies___
# of live births___
# of premature births___
# of miscarriages___
# of abortions___
Date of last period_____
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Neuropsychological
__ Seizures
__ Areas of numbness
__ Concussion
__ Bad Temper
__ Treated in past for emotional issues
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__ Lack of coordination
__ Depression
__ Easily susceptible to stress
__ Ever considered suicide?
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__ Loss of balance
__ Poor memory
__ Anxiety
__ Tremors
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Comments:
Anything else you would like to discuss?
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