Turning point Acupuncture
519 N. Leroux St.
Flagstaff, AZ 86001
(928) 606-2454
This is a confidential record of your medical history and will be kept in my files. Information contained here will not be released without your written authorization.
Name______Date______
Age______Date of birth______Gender______
Address______zip______
Telephone (h)______(c)______(w)______
Email______
Occupation______
Employer______
Do you enjoy your work? ______
Live with: Spouse Parents children friends pets alone
Emergency contact person______Phone #______
How did you hear about Turning Point Acupuncture?______
Health History
What are your most important health concerns? What brings you here today?
Other concerns?
Please list medications, vitamins, supplements and herbs that you are taking.
Have you been tested for HIV?______Result______When?______
Have you been tested for Hepatitis?______Result______When?______
Are you pregnant?______
Please List surgeries and dates:
Do you have any food sensitivities?
Weight_____ Weight 1 year ago_____ Weight you feel good at______
Review of systems:
Y=present P=past N=never
Emotional
Mood swings Y P N Depression Y P N
Considered/attempted suicide Y P N Anxiety Y P N
Panic attacks Y P N High stress Y P N
Suffer from verbal/physical
abuse Y P N Abuse others Y P N
Endocrine
Hyper/hypo thyroid Y P N Diabetes Y P N
Hot or cold intolerance Y P N Hypoglycemia Y P N
Seasonal depression Y P N Excess hunger Y P N
Excess thirst Y P N Excess fatigue Y P N
Immune
Chronic fatigue syndrome Y P N Slow healing Y P N
Neurological
Vertigo/dizziness Y P N Paralysis Y P N
Numbness/tingling Y P N Easily stressed Y P N
Loss of balance Y P N Seizures Y P N
Muscle weakness Y P N Memory loss Y P N
Skin
Rashes Y P N Eczema/hives Y P N
Itching Y P N Color changes Y P N
Lumps Y P N Hair loss Y P N
Head
Headaches Y P N Head injury Y P N
Migraines Y P N TMJ/clenching jaw Y P N
Eyes
Spots in vision Y P N Cataracts Y P N
Impaired vision Y P N Eye pain Y P N
Glaucoma Y P N Tearing/dryness Y P N
Ears
Impaired hearing Y P N Ringing Y P N
Ear aches Y P N
Nose/Sinuses
Frequent colds Y P N Nose bleeds Y P N
Stuffiness Y P N Allergies Y P N
Sinus infections Y P N Loss of smell Y P N
Sinus headaches Y P N
Mouth/Throat
Tongue/lip sores Y P N “soft teeth” Y P N
Gum disease Y P N lots of dental work Y P N
Respiratory
Chronic cough Y P N Asthma Y P N
Emphysema Y P N Pain on breathing Y P N
Bronchitis Y P N Short of breath Y P N
Reproductive/Male
Low sperm count Y P N Difficulty with erections Y P N
Waking to urinate Y P N Prostate issues Y P N
STD Y P N
Reproductive/Female
Difficulty conceiving Y P N # of pregnancies _____
STD Y P N # of births _____
PMS Y P N # of miscarriages _____
Menopausal symptoms Y P N Breast lumps _____
Abnormal PAP Y N P
Musculoskeletal
Joint pain Y P N Arthritis Y P N
Broken bones Y P N Muscle cramps/spasms Y P N
Sciatica Y P N
Vascular
Easy bruising/bleeding Y P N Anemia Y P N
Deep leg pain Y P N Cold hands/feet Y P N
Varicose veins Y P N Phlebitis's Y P N
Sleep
Trouble falling Y P N Vivid dreams Y P N
Sleep walking Y P N Night sweats Y P N
Waking in night Y P N Groggy awakening Y P N
Waking to urinate Y P N
What time of the day is your energy: Best?______Worst?______
Are you in Pain? Please indicate location(s), type and severity.
Family History
Age
Cancer
Diabetes
Heart Dz.
HTN
Stroke
Mental health
Asthma
Thyroid
Habits
What are your hobbies and interests?
Do you exercise?
Do you have a religious or spiritual practice? Is it fulfilling?
Do you express your emotions?
Do you eat three meals a day? What is your typical diet?
AM
Noon
PM
Snacks
I like: (please circle)
Sour Spicy Sweet Bland Salty ______
I don't like:
Sour Spicy Sweet Bland Salty ______
I crave:______
I watch TV_____hours per day/week.
Have you been treated for alcohol or drug addiction? Y N
Are you addicted to anything? Y N
Do you drink coffee Y N How much?_____
Do you drink black tea Y N How much?_____
Do you drink soda? Y N How much?_____
Do you eat sugar? Y N How often?_____
Do you use tobacco? Y N How much?_____
Do you go on diets often? Y N
Do you drink alcohol? Y N How much?_____
Do you drink water? Y N How much?_____
Do you spend time outdoors? Y N How often?_____
Do you have a supportive relationship? Y N
How does your condition affect your life? (Anything positive about it?)
What do you feel/think needs to happen to better your quality of life?
How much change are you willing to make at this time to improve your health?
Minimal------some------complete
Anything you'd like to add?
1