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Please Call: 408.583.7964 for an appointment.

Monday: 10am-6pm
Wednesday: 1pm-7pm
Thursday 10am-7pm

List of Medical Services

Initial consultation: $185
Accupuncture: $85
Herb. Med. Consult.: $85

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Health History Questionaire for Patients

HEALTH HISTORY QUESTIONNAIRE FOR PATIENTS

Welcome to Our Clinic! Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All your answers will be held absolutely confidential. If you have questions, please ask us. If there is anything you wish to bring to our attention which is not asked on this form, please note it in the COMMENTS section. Thank you!

Name

Street

City

State

Zip Code

Age

Sex

Height

Weight

Home Phone

Work Phone

Date/Place of Birth

Social Security Number

Employment Status

Marital Status

In Emergency, Notify

Referred by

Family Physician

Primary Insurance

Insurance Holder

Plan

Member ID#

Group #

Claims Address

Primary Insurance Phone #

Have you tried acupuncture or Chinese herbal medicine before?

MAIN PROBLEM(S) YOU WOULD LIKE TO ADDRESS

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

When did you first notice any symptoms?

Have you been given a diagnosis for the problem by your family physician?

If so, what is it ?

What kinds of treatment or therapy have you tried?

Any other significant illnesses?

Any accidents or significant trauma?

OTHER RELEVANT MEDICAL HISTORY

OCCUPATION

Occupational stress factors (physical, psychological, chemical)

LIFESTYLE

Do you follow a regular exercise program?

If so, please describe

Please describe your average daily diet

Do any of the following habits that apply- Cigarette smoking - Coffee, tea or cola - Alcoholic beverages. How much and how often do you use them?

List medications taken within the last two months (vitamins, drugs, herbs, etc.)

Please describe any use of drugs for non-medical purposes

PLEASE PUT A CHECK NEXT TO ANY CONDITIONS YOU HAVE EXPERIENCED WITHIN THE LAST THREE MONTHS INDICATE THE LENGTH OF TIME YOU HAVE HAD THIS CONDITION.

Other unusual or abnormal conditions you have noticed in your general sense of health

Any other hair or skin problems?

Any other head or neck problem?

Any other heart or blood vessel problems?

Any other lung problems?

Any other problems with stomach or intestines?

Do you wake up at night to urinate? If so, how often?

Any particular color to your urine?

Any other genital or urinary problems?

Age at menopause

Age at first menses

Number of pregnancies

Time between cycles

Duration of bleeding

First day of last menses

Do you practice birth control...and if so, what type?

For how long?

Any other gynecologic?

PATIENT INFORMATION SHEET

Any other joint or bone problems?

Have you ever been treated for emotional problems? If so, please explain.

Have you ever considered or attempted suicide?

Any other neurological or psychological problems?

COMMENTS

Please list any other problems you would like to discuss

PATIENT COMMENTS

What are the most important things to you in life?

If you wanted 3 things to be better about your health, what would they be?

What is important to you about seeing an acupuncturist?

What are the best methods of healing support that you have experienced in your life, so far?

What things do you respond positively to?

What things do you respond negatively to?

What would your ideal life look like?

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September 2010

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