The Present Sage Acupuncture

New Patient Health History

THI S INFORMATION IS CONFIDENTIAL

Principle complaint:

Is condition worsening? (please specify) ______

What makes it better? (Rest, movement, certain foods, heat, cold, fresh air, emotional expression, etc.) ______

What makes it worse? (Overwork, fatigue, emotional suppression, hunger, heat, certain foods, damp days etc.) ______

What has been diagnosed (by your M.D.)?

______

Do you have other symptoms you would like to address, or treatment goals you would like to achieve? ______

General health and wellbeing

Please check if you have had any of the items listed below in the last year.

Put a Pin the box if you had this item in the past but no longer have it.

Fatigue / Change in appetite / Muscle weakness/fatigue
Chills / Poor appetite / Localized weakness
Fevers / Weight loss/gain / Poor balance
Night sweats / Cravings / Tremors
Sweats Easily / Strong thirst (hot or cold drinks) / Sudden energy drop
Poor sleeping / Peculiar tastes/smells
Bleed/bruise easily / Dental/gum problems

Skin and hair

Rashes / Acne / Loss of hair
Itching / Eczema/Psoriasis / Fungal Infection
Dandruff / Recent moles / Weak nails
Hives/Allergic Dermatitis

Head, eyes, ears, nose and throat

Recurrent sore throats/colds / Cataracts / Sores on lips/tongue
Headaches / Spots in front of eyes / Earaches
Migraines / Night Blindness / Ringing in ears
Sinus problems / Nose bleeds / Poor hearing
Dizziness / Dental problems / Difficulty swallowing
Poor vision / Jaw clicks/locks / Grinding teeth
Eye pain

Cardiovascular

Palpitations / Pain or pressure in chest / Swelling of hands/feet
Fast pulse (over 100 beats/minute) / Shortness of breath / Cold hands/feet
Slow pulse (less than 60 beats/minute) / Dizziness / Cold sweats
Irregular heart beat / Fainting / Phlebitis
Low blood pressure / Varicose veins / Anemia
High blood pressure / Blood clots

Please check if you have had any of the items listed below in the last year.

Put a Pin the box if you had this item in the past but no longer have it.

Respiratory

Cough/Wheezing / Bronchitis / Tight sensation in chest
Asthma / Pain with deep inhalation / Production of phlegm
Pneumonia / Difficulty inhaling/exhaling

Gastrointestinal

Constipation / Intestinal gas / Pancreatitis
Chronic laxative use / Heartburn / Illeocecal valve syndrome
Diarrhea / Nausea or vomiting / GI tumors
Loose stools / No appetite / IBS/Crohn’s Disease
Abdominal pain / Excessive appetite / Polyps
Indigestion / Significant thirst / Ulcers
Belching / Bad breath / Peritonitis
Bloating / Hemorrhoids

Neuropsychological & emotional

Nervousness / Hopelessness / Headaches
Anxiety/panic attacks / Easily susceptible to stress / Concussion
Depression / Seasonal Affective Disorder / Seizures
Easily irritated / Substance Abuse
Frequent emotional “ups and downs” / Vertigo/Dizziness

Urinary

Infections / Decreased libido / Copious flow
Blood in urine / Excessive libido / Night urination
Unable to hold urine / Frequent urination / Sores on genitals
Scanty flow / Urgent urination / Kidney stones
Burning urination / Pain on urination / Herpes
Urinary tract infection

Musculoskeletal

Neck pain / Carpal Tunnel / Bursitis
Back pain lower/middle/upper / Foot/ankle pain / Tendonitis
Shoulder pain / Hip pain / Muscle pain
Rotator Cuff / Sciatica / Muscle weakness
Hand/wrist pain

Male sexual health

Prostatitis / Pain in testicles / Premature ejaculation
Lumps n testicles / Increased libido / Nocturnal emission
Pain/Itching of genitalia / Decreased libido / Impotence

Please check if you have had any of the items listed below in the last year.

Put a P in the box if you had this item in the past but no longer have it.

Female gynecological/reproductive

Age of first menses _____ / Vaginal discharge / Endometriosis
Date of last menses ______/ Vaginal dryness / Difficult/painful intercourse
PMS / Uterine Fibroids / Date of last PAP/Pelvic exam ______
Irregular menstruation / Polycystic Ovarian Disease / Infertility

Medical history

Illnesses, surgeries, accidents

Childhood:

______age ______age ______age ___

Adolescence:

______age ______age ______age ___

Adulthood:

______age ______age ______age ___

Do you have any scars? Note location of all scars from operations or injuries (including minor ones.)

______

Family medical history Please check any condition that applies to your family and list family member.

Diabetes______/ Emotional disorder______/ Allergies______
Heart Disease______/ Seizures______/ High Blood Pressure ______
Asthma______/ Stroke ______/ Neurological disorder______
Cancer______

Other:______

______

Medical diagnoses Please check any conditions or symptoms you currently have.
Arthritis / Anemia / Respiratory Allergies
High/Low Blood Pressure / Hypo/Hyperglycemia / Asthma
Raynaud’s Disease / Food Allergies/Intolerance / Emphysema
High Cholesterol / Gastritis/Pancreatitis / Chronic Fatigue
Heart Disease / Liver/Gall Bladder Disease / Lyme Disease/Tick-borne illness
Stroke / Diverticulitis/IBS / Chronic Pain Condition
Hepatitis / Ulcer / Intestinal parasites
Medical diagnoses (cont.) Please check any conditions or symptoms you currently have.
Alcoholism / Diabetes / Impotence
Kidney Disease / Thyroid Imbalance / Chronic Fatigue
Cancer / Seizures / Fibromyalgia

Other:______

______

Medications Please list all medications, vitamins, and/or food supplements you are currently taking.

Medication ______Dosage ______For what condition? ______

Medication ______Dosage ______For what condition? ______

Medication ______Dosage ______For what condition? ______

Vitamins ______

Food Supplements ______

Allergies or reactions to medications: ______

Health maintenance screening tests

Lipid (cholesterol)Date ______Abnormal? _____

Sigmoidoscopy or ColonoscopyDate ______Abnormal? _____

Women

MammogramDate______Abnormal?_____

Pap SmearDate______Abnormal?_____

Dexascan (osteoporosis) Date______Abnormal?_____

Men

PSA (prostate) Date______Abnormal?_____

Lifestyle

For each item below, indicate how much, how many, or how often if applicable. Indicate whether this is a current habit or provide the date that you quit.

Cigarettes (packs per day) ______Coffee/Tea (cups per day) ______

Alcohol (drinks per week) ______Soda (regular or diet) ______

Drug use (recreational)______

ExerciseYes NoType of exercise(s) ______

How often? ______If you don’t exercise, why not?______

Diet

Please indicate if your diet is:

VegetarianVeganGluten-Free Primarily organicSpecial dietary restrictions

Typical Breakfast ______

Lunch______

Dinner______

Snacks______

Overall energy level (rate from 1-10) _____ Is this better or worse than your experience of energy levels in the past? (please comment) ______

Menstrual cycle

Amount of flow (normal, heavy, light)______

Length of cycle ______Clotting (large, small, black, purple, red, other) ______

Cramps:(dull or sharp, location) ______

Breast tenderness Cravings Mood swings Anger/frustration

Do you practice birth control?______What type?______How long?______

Number of live births ______Number of miscarriages ______

Please indicate if the miscarriage took place during the first, second, or third trimester(s).

Additional information Is there anything else you would like us to know?

______

______

______

Patient Signature Date

1

The Present Sage Acupuncture | 822 Montgomery Ave. Ste. 316 Narberth, PA 19072