127 W. Bell St., Sequim, WA 98382

Health History Questionnaire

Name: Date:

Street Address:

City:State:Zip:

Home Phone:Work Phone: Cell:

~ Please circle your preferred contact number for reminder calls ~

Email:

Birth Date:Birth Time (If known): Birth place:Age:

In Emergency, please contact: Phone:

How did you hear about us?

Have you had acupuncture? Have you taken Chinese herbs?

#1 Reason for contacting our office: ______

Date of injury: ______If not an injury, when did the problem begin?______

Please describe your symptoms and what makes them better or worse:______

______

Has a medical diagnosis been given to this problem?______What?______

Previous treatments and results:______

______

#2 Reason for contacting our office: ______

Date of injury: ______If not an injury, when did the problem begin?______

Please describe your symptoms and what makes them better or worse:______

______

Has a medical diagnosis been given to this problem?______What?______

Previous treatments and results:______

______

Additional Health Issues: #3 ______#4 ______

#5 ______#6 ______#7 ______

#8 ______#9 ______#10 ______

Last Doctor's appointment (Date & Reason): ______

______

Sorenson Acupuncture - Health History Questionnaire

Pain Profile

The pain quality is:

SharpBurningAching

CrampingDullMoving

Fixed Other:______

What reduces the pain?

PressureColdHeat

Exercise Other______

Whatincreases the pain?

PressureColdHeat

Please circle all that apply to you:

PregnantBleeding Disorder PacemakerHepatitisSeizures

HIVHigh Blood Pressure Surgical MeshChemo/Radiation

Please list any allergies and reactions (Drugs, chemicals, foods, environmental, or other):

______

Medications/ Vitamins/Supplements/Herbs:Reason for taking it:

______

Sorenson Acupuncture - Health History Questionnaire

Physical Traumas & Surgeries: ______

Illness & Disease: ______

Family Medical History: (Stroke, heart disease, high/low blood pressure, cancer, skin disease, mental/emotional disorder, seizures, asthma, allergies, substance abuse, diabetes, other)

Father: ______

Mother: ______

Siblings: ______

Grandparents: ______

Are you on a restricted diet? ______if yes, please describe: ______

______

Please indicate the amount and frequency (Amountperday, week, month)

Cigarettes:______per ______Marijuana: ______per ______Alcohol: ______per ______

Coffee: ______per ______Tea: ______per ______Soda: ______per ______

What is your work?______Do you enjoy it?______

If not working, what are your main activities?______

What is your current stress level (Scale of 1-10)?______

What are your stressors?______

What do you do to relieve stress and/or relax?______

How much time do you spend daily watching TV/Movies? ______On computer?______

Do you exercise regularly? Please describe: ______

______

What time do you usually fall asleep?______Wake? ______Hours of sleep? ______

How long does it take you to fall asleep?______Do you wake in the morning feeling rested?______

Do you awake during the night? ______# of times? ______Reason? ______

Do you nap during the day? _____ How long? ______Rate your general energy 1-10 ______

When is your best/most productive time of day?______Lowest/least productive?______

Emotions have physical effects on health; please rate your daily emotions on a scale of 1-5:

Anger...... 0 1 2 3 4 5

Frustration...... 0 1 2 3 4 5

Joy/Happiness...... 0 1 2 3 4 5

Worry/Anxiety...... 0 1 2 3 4 5

Sadness...... 0 1 2 3 4 5

Fear/Phobias...... 0 1 2 3 4 5

Grief/Sorrow...... 0 1 2 3 4 5

General (Check all that apply):

Poor appetiteLocalized weaknessSudden energy dropPoor sleep

Fevers

Bruise or bleed easily

Weight gain

Weight loss

Chills

Sweat easily

Peculiar tastes or smell

Tremors

Poor balance

Strong thirst

Thirst without desire to drink

Fatigue

Night sweats

Cravings - for what?

Sorenson Acupuncture - Health History Questionnaire

Overall Temperature (Yin & Yang): These symptoms indicate imbalance of Yin and Yang in your body. Yin is the cool, moist, nourishing aspect of the body. Yang is the hot, dry, invigorating aspect of the body.

Cold hands/feet Sweaty hands/feet Hot body area

Cold body area

Afternoon flushes

Night sweats

Heat in chest

Hot flashes

Perspire easily

Lack of perspiration

Thirsty

Take water to bed

Overall Energy & Immunity):

Shortness of breath Difficulty staying awake during daytime

General weakness

Easily catch colds

Low energy

Feel worse after exercise

Auto Immune diagnosis

Heart function: These symptoms are indicators of heart imbalance. The heart governs the blood & blood vessels, manifests in the complexion, rules emotions, affects speech, taste, and controls perspiration.

Palpitations

Irregular heartbeat

Anxiety

Sores on tongue tip

Restlessness

Mental confusion Chest pain

Frequent dreams

Foot swelling

Other ______

Wake unrefreshed

Drink coffee(cups per week: ______)

Dizziness

Lung function: These symptomsare indicators of lung imbalance. The lungs govern breathing, control the movement of energy, control the immune system, regulate water passages, manifest in the skin and open to the nose, throat, and sinuses.

Asthma

Bronchitis

Cough

Nose Bleeds

Sinus Congestion

Nasal Discharge

(Color: ______)

Dry mouthor throat

Sore throat

Dry sinuses orskin

Allergies (To what? ______)

Sneezing

Difficulty breathing

Breathing pain

Spleen/Pancreas function: These symptomsare indicators of spleen/pancreas malfunction.The spleen/pancreas assists in breaking food down into usable nutrients and transports them throughout the body, keeps the blood in the vessels, governs the muscles, manifests in the lips and holds the organs up in the body.

Low appetite

Abrupt weight gain Abrupt weight loss Abdominal bloating

Abdominal gas

Gurgling in stomach Fatigue after eating

Prolapsed organs (which______)

Easily bruised Hemorrhoids

Over-thinking

Worry

Dampness, Fluid metabolism: Refers to fluids that are not metabolized effectively and cause health problems in the body. Dampness is considered pathologic fluid.

General sensation of heaviness in the body Mental heaviness

Mental sluggishness Mental fogginess

Swollen hands

Swollen feet

Swollen joints

Chest congestion

Nausea

Sorenson Acupuncture - Health History Questionnaire

Digestive functions: The following symptoms are indicators of digestive malfunction.This system controls the breakdown and absorption of food and nutrients, descends movement and is the origin of the body’s fluids.

Loose stools

Diarrhea

Incomplete bowel movement

Constipation

Blood in stools Mucous in stools Undigested food in stools

Stomach pain/cramps

Nausea

Vomiting

Bad breath

Gas

Frequentlybelching

Black stools

Blood in stools

Irritable bowel

Use laxatives regularly

Other ______

Large appetite

Mouth (canker) sores

Bleeding, swollen or painful gums

Heartburn

Acid regurgitation

Ulcer (diagnosed)

Belching

Hiccoughs

Stomach pain

Liver, Gall Bladder function: The following symptoms indicate liver imbalance.The liver stores blood, ensures the smooth flow of qi and blood throughout the body, nourishes the tendons and ligaments, manifests in the nails and opens to the eyes.The gall bladder stores bile, which breaks down fats.

Alternating diarrhea and constipation Chest pain

Tight sensation in chest

Bitter taste in mouth Anger easily Frustration Depression Irritability

Dizziness

Frequently difficulty adapting to stress

Reason for stress? ______

Skin rashes

Headache - top of head Tingling/numbness

Spasm, twitching

Seizures

Convulsions

Neck tension

Shoulder tension

Drink alcohol (type______, Quantity per week______)

Highpitched ringing Gall stones (past or current)

Eyes:

Itchy

Bloodshot

Hot

Dry

Watery

Gritty

See floating spots in eyes

Blurry vision

Decreased night vision Near-sighted

Far-sighted

Kidney, Urinary Bladder function:The following symptoms are indicators of kidney or urinary bladder imbalance.The kidney and adrenal system rule birthdevelopment, growthreproduction; produces marrow, nourish the brain, control bones, govern water, open to the ears, manifest in hair, control the ureter/spermaticduct and lower section of the large intestine.The urinary bladder stores and eliminates impure fluids.

Frequent cavities Easily broken bones Sore knees

Weak knees

Cold knees

Low back pain

Memory problems Excessive hair loss

Urination:

Color:

light yellow Dark yellow

Clear Reddish

Cloudy

Amount:

Little

Profuse

Other

Strong odor

Burning

Painful

Difficult

Urgent

Sorenson Acupuncture - Health History Questionnaire

Libido (Sex Drive): Normal High Low

MEN ONLY:

Low sperm count

Poor sperm quality

Poor sperm motility

Impotence

Exhaustion after sex

Premature ejaculation

Swollen testes

Testicular pain

Coldness or numbness in external genitalia Other______

WOMEN ONLY:

Regular menstrual cycle? Y N Might you currently be pregnant?Y N

Number of pregnancies:______Number of children:______

Age of first menstruation:______Age of menopause (if applicable):______

Average number of days of flow:______Average # days of entire cycle:______

 Unusual vaginal discharge (color,odor, consistency)

Bleeding or spotting between periods

Do you experience any of the following pre-menstrual symptoms?

nausea vomiting

water retention

breast swelling

food cravings headaches

migraines

breast tenderness depression

irritability

anxiety

other emotions:______

dull pain,

where?______sharp pain, where?______

Day 1 / Day 2 / Day 3 / Day 4 / Day 5 / Day 6 / Day 7
Color (bright red, pale, brown, rust, dark, purple, other)
Flow (normal, heavy, light)
Pain/cramps (location, dull, sharp, other)
Clots (large, small, black, purple, red, other)
Vomiting (check if yes)
Nausea (check if yes)
Other

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