Patient Medical History

Karen Castle, MA, Dr of Oriental Medicine, Licensed Acupuncturist

PATIENT MEDICAL HISTORY

Name:______Date______

Please circle the any of the following conditions below that currently affect you or you have experienced in the past 5 years.

GENERAL CARDIOVASCULAR GYNECOLOGY

Poor appetite High Blood Pressure Number of Pregnancies___

Increased appetite Low Blood Pressure Number of Births______

Weight Change Chest Pain Miscarriage______

Poor sleep or insomnia Irregular Heartbeat Age at first menses______

Too much sleep Dizziness Cramps (when)______

Fatigue Fainting Irregular Periods

Tremors/Shaky hands Cold hands/feet Excess Bleeding

Vertigo Swelling hands/feet Last PAP______

Cold hands/feet Difficulty Breathing Last Menses______

Cold back/abdomen Palpitations

Aversion to Wind Other______NEURO/PSYCHOLOGICAL

Fevers Seizures

Chills SKIN AND HAIR Areas of numbness

Night Sweats Acne/Pimples Poor Memory

Sweat Easily Rashes Concussion (when)______

Athlete’s Foot Ulcerations Depression/Anxiety

Food Cravings Hives Angry easy/irritated

(sweet, salty, sour) Itching Treated for emotional disorder

Localized weakness Eczema Considered/Attempted suicide

Poor coordination Other skin problems Other

Memory Loss ______

Sudden energy drop at

Peculiar taste/smells GASTROINTESTINAL/ HEAD,EARS,EYES,NOSE,

Prefer hot drinks DIGESTIVE Colds frequently

Strong thirst (cold or hot) Nausea/Vomiting Dizziness

Bleed or bruise easily Diarrhea/Constipation Migraines/Headaches

Lymph node enlargement Gas Concussion

Belching Glasses/ Contacts

MUSCULOSKELETAL Abdominal distention Eye Strain

Ankle / foot pain Abdominal bloating Blurry vision

Back pain Hiccups Poor Vision

Knee/ let sciatica pain Indigestion Night Blindness

Neck pain Bowel Movement Earaches

Shoulder pain ______Frequently Ringing in ears

Wrist/elbow pain ______Color Poor hearing

TMJ Jaw pain Bloody stool Nose Bleeds

Other ______Use Laxatives Sinus Problems

Allergies

RESPIRATORY GENITOURINARY Mucus

Cough Pain on urination Dry Throat/Mouth

Coughing blood Frequent urination Excess saliva

Asthma Urgency to urinate Gum problems

Pneumonia Unable to hold urine Jaw clicking (TMJ)

Bronchitis Blood in urine Grind Teeth

Difficulty Breathing Kidney stones Facial pain

Tight chest Venereal disease Sores on lips or tongue

Production of phlegm Impotency Tonsilitis

What color______Urinary Tract infection Laryngitis