Health History Questionnaire

(Please Print)

This is a CONFIDENTIAL questionnaire to help determine the best treatment plan for you. If you have any question, please ask.

Personal Information

Today’s Date ____/____/___

Patient’s Last NameFirstMiddleMr.MissMarital Status (Check One): Single/Married

Mrs.s.Divorced/ Separated/ Widowed/ Partnered

______

Is this your legal name?If not, what is your legal name?(Former Name)Birth DateAge Sex

Yes No / / M F

Height______Weight ______

______

AddressHome Phone No.

______(____)______

CityStateZipCellular Phone No.

______(____)______

OccupationEmployerEmployer Phone No.

______(____)______

Person Responsible for AccountAddress (if different)Home Phone No.

Emergency Contact: Name ______Phone ______

Referred by (Please check one box) Dr.______ Web ______

Family/Friend ______ Sierra ScoopOther______

Would you like to receive our

Email newsletter? Yes NoEmail Address:

Health Information

Have you received acupuncture therapy before?  Yes  No When? ______With Whom? ______

List any medications and nutritional supplements (including Herbs) you are currently taking: (Continue on back if necessary)

MedicineDosageReasonHow longPrescribed by

______

What are the main health concerns for which you are seeking treatment?

______

______

List any other health problems you now have.

______

______

List any accidents, surgeries, or hospitalizations

______

______

List any medications or foods you are allergic to:

______

Please indicate any significant illnesses you or a blood relative (Grandparent, parent or sibling) have had:

IllnessYou Your Approx.IllnessYou Your Approx.

RelativeDateRelativeDate

Cancer______Diabetes______

Hepatitis______Heart Disease______

High Blood ______Seizures______

Pressure

Rheumatic Fever______Emotional______

disorders

Infectious Diseases______Tuberculosis______

Sexually Transmitted Diseases:  Gonorrhea  Syphillis  HIV  HPV  Chlamydia  Herpes

Check the Box if any of the following statements are true:

 □ I am taking Coumadin/Warfarin

□ I have a pacemaker

□I am taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs)

OB/GYN History

Age of 1st period (menarche) ______Are you pregnant? Yes No# of pregnancies ______

Age of last period (menopause) ______# of live births _____ # of Abortions ______# Miscarriages _____

Number of days between periods ______Date of last: Gynecologic exam ______Pap Smear ______

Number of days of flow ______Mammogram ______Bone Density Scan ______

Color of flow: normal bright red paleResults ______

dark rust brown purple other______

Clots?YesNoColor ______

Have you been diagnosed with: FibroidsFibrocystic BreastsEndometriosis Ovarian Cysts PID

Location of Pain:Lower abdomenLower backThighsOther ______

Nature of Pain (please indicate before, during and after menses)Other Symptoms related to menses:

Cramping______Stabbing ______DischargeVaginal dryness Headache

Burning ______Aching ______NauseaConstipation Diarrhea

Dull ______Bloating ______Swollen Breasts Mood swings Insomnia

Consistent ______Intermittent ______Ravenous appetite Poor appetite Hot flashes

Bearing down sensation ______Increased libido Decreased libido Night Sweats

Urogenital History

Date of last prostate check up ______PSA results ______Manual prostate exam results ______

Lab results ______

Frequency of Urination: daytime ______nighttime ______Color of urine:  clear murky odor: ______

Symptoms related to prostate

prostate problemsDelayed streamPost void dribblingIncontinenceRetention of Urine

Erectile dysfunction (ed)Increased libidoDecreased libidoPremature ejaculation

Back painGroin painTesticular painDecreased force of stream

ImpotenceBPH/Enlarged prostateother______

Symptom Survey

The following is a list of symptoms that you may or may not ever experience. Please indicate as follows: no mark ( ) = never experience check mark (√) = sometimes experience Plus (+) = frequently experience

—cough

—shortness of breath

—decreased sense of smell

—nasal problems

—skin problems

—feeling of claustrophobia

— bronchitis

—colitis or diverticulitis

— constipation

—hemorrhoids

—recent use of antibiotics

—sadness/grieving

—allergies:______

—headache

—sore throat

—asthma

— tendency to catch colds

۞۞۞

—lack of appetite

—excessive appetite

—loose stool or diarrhea

—digestive problems, indigestion

—vomiting

—belching, burping

—heartburn/reflux

—retention of food in the stomach

— tendency to become obsessive in

work and relationships…

—easily bruised

—mucous/blood in stool

—frequent canker sores

—mental fogginess

—edema

—nausea

—snoring

—general sensation of heaviness

in body

— # of bowel movements per day ______

۞۞۞

—insomnia, difficulty sleeping

— heart palpitations

—cold hands and feet

—nightmares

—mentally restless

— laughing for no apparent reason

— angina pains

— abdominal pain

— chest pain

— headaches

— anxiety

— dizziness

— sores on tip of tongue

— sadness

۞۞۞

— low back pain

— sciatic pain

— knee problems

— hearing impairment

— ear ringing

— kidney stones

— decreased sex drive

— hair loss

— urinary problems

— fearful

— night sweats

— body temperature

sensationhotcold

— frequent or urgent urination

— facial flushing

— hot flashes

— bone problems

۞۞۞

— eye problems

— jaundice (yellowish eyes/skin)

— difficulty digesting oily foods

— gall stones

— light colored stool

— soft or brittle nails

— easily angered or agitated

— difficulty in making plans

or decisions

— spasms or twitching of muscles

— eyes

itchy bloodshot dry

blurry vision floaters

— tightness in chest

— bitter taste in mouth

— frustrated/irritable

— skin rashes

— sensation of lump in throat area

— pain or coldness in genital area

Please clearly mark any areas of pain:

Is the pain: Sharp Burning

 Aching  Fixed Cramping

 Dull Moving

 Other: ______

Do the following lessen the pain?

 Pressure Cold Heat

 Exercise Other: ______

Do the following worsen the pain?

 Pressure Cold Heat

 Other: ______



David Edge, OMD

1528 Highway 395, Suite 215

Gardnerville NV 89410

(775)783-4930

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge that I have received a copy of David Edge, OMD’s Notice of Privacy Practices. This Notice describes how David Edge, OMD may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protect health information.

______

(Signature on Patient, or Personal Representative)Date

Assignment and Release

I hereby authorize payment of insurance benefits be made directly to David Edge, OMD. I understand that I am responsible for charges not covered by this assignment. I further authorize the release of any information required to process claims.

______

(Signature on Patient, or Personal Representative)Date

Non-Covered Medicare

Medicare does not cover Acupuncture, and there is no guarantee that your secondary insurance will cover. In order to receive a Medicare denial, required by most secondary insurance for consideration of payment, please enter your Medicare ID number here ______

As a courtesy, we will bill your secondary insurance. If we do not receive payment within 60 days, you will be responsible for payment in full for your outstanding balance.

______

(Signature on Patient, or Personal Representative)Date