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Pre/Post-Surgical Manual Lymphatic Drainage
Therapeutic Bodywork
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Manual Lymphatic Drainage Intake
Therapeutic Massage Intake
Children & Teens Intake
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Acupuncture Health History Form
Patient Information
Name
Date
MM slash DD slash YYYY
Address
City
State
Zip
Home Phone
Cell Phone
Height
Weight
Marital Status
Sex
Male
Female
Non-Binary
Occupation
Employer
Have You Had Acupuncture Before
Yes
No
If Yes Name of Acupuncturist
Major Complaint
Primary reason for your visit today?
Has this condition been diagnoised by a physician or other provider?
No
Yes
Diagnosis
Are you being treated for this condition by anyone else?
Yes
Somewhat
Not Much
Not At All
If yes, what is the treatment?
How does this condition affect you?
How long have you had this condition?
Personal Health History
Your general health as a child was?
Excellent
Good
Average
Poor
Did you feel nurtured as a child?
Allways
Usually
Sometimes
Never
Check all the illnesses or conditions which you currently have or have had in the past
AIDS / HIV
Alcoholism
Allergies
Antibiotic Use
Asthma
Bleed Easily
Cancer
Chicken Pox
Diabetes
Drug Abuse
Eating Disorders
Epilepsy
Glaucoma
Heart Disease
Hepatitis
High Blood Pressure
High Fevers
Hyperthyroid
Hypothyroid
Jaundice
Kidney Disease
Measles
Meningitis
Mental Illness
Multiple Sclerosis
Mumps
Obesity
Pneumonia
Polio
Other
Rheumatic Fever
Scarlet Fever
Sexually Transmitted Disease
Stroke
Tuberculosis
Typhoid Fever
Ulcers
Vascular Disease
If selected other please specify
Are you taking Coumadin or Warfarin?
Yes
No
Do you have seizures?
Yes
No
Do you have a pacemaker?
Yes
No
Do you currently have any infectious diseases?
Yes
No
Possibly
If yes, please identify:
HIV / AIDS
Hepatitis B
Hepatits C
Flu / Cold
Streptococcus
Mononucleosis
Tuberculosis
Other
Known or suspected allergies
Personal Health Inventory
Please select all the symptoms that you currently have or have experienced in the last couple months.
Qi, Blood, Yin, Yang
anxiety
catches colds easilyor frequently
chest pain traveling to shoulder
cold feet
cold hands
difficult to concentrate
dizziness
dream disturbed sleep
dry skin
fatigue
feverish in the afternoon or flushes
general weakness
heat sensations in hands, feet, chest
insomnia
mental confusion
night sweats
palpitations
restlessness
sores on tip of tongue
speech problems
sweats easily
thirst, at night
you feel worse after exercise
you see floating black spots
LU
allergies
chills alternating with fever
cough
difficulty breathing
dry mouth, throat, nose
feeling achy
headaches
nasal discharge
nose bleeds
shortness of breath
sinus congestion
sneezing
sore throat
stiff neck/ shoulders
SP
abdominal bloating and / or gas after eating
belching
chest congestion
constipation
diarrhea
eating disorders
fatigue after eating
gas
general feeling of heaviness in your body
hemorrhoids
loose stools
low appetite
mental heaviness, sluggishness or fogginess
nausea
prolapsed organs (previously diagnosed)
swollen feet
swollen hands
you bruise easily
ST
bad breath
belching
bleeding, swollen or painful gums
burning sensation after eating
constipation
heartburn
large appetite
mouth sores (canker or cold sores)
stomach pain
vomiting
HT / PC
chest pain
edema
high blood pressure
insomnia
low blood pressure
palpitations
stroke
varicose veins
LR / GB
bitter taste in mouth
blood shot eyes
blurred vision
chest pain
convulsions
diarrhea alternating with constipation
difficulty swallowing
dry eyes
feeling of a lump in your throat
headache at the top of your head
hot flashes
muscle spasms, twitching, cramping
numbness of hands and feet
pain in rib cage
red, sore or irritated eyes
seizures
skin rashes
tight feeling in chest
TMJ or locked jaw
you anger easily
you feel better after exercise
KI / BL
frequent urination
hair loss
joint pain
lack of bladder control
loose teeth
low back pain
memory problems
night blindness or low vision
ringing in your ears
sore, cold or weak knees
you get up more than one time at night to urinate
Other
Family History
How do you feel about the following areas of your life in the past month.
Signficant Other
Great
Good
Fair
Poor
N/A
Family
Great
Good
Fair
Poor
N/A
Self
Great
Good
Fair
Poor
N/A
Check illnesses which have occurred in any of your blood relatives
Alcoholism
Cancer
Heart Disease
Mental Illness
Allergies
Diabetes
High Blood Pressure
Obesity
Bleed Easily
Epilepsy
Kidney Disease
Stroke
Other
If other please specify
Women Only
Are you pregnant?
Yes
No
Trying
Maybe
If yes how many months?
Method of birth control?
Age of First Menses
Date of Last Menses
Age of Menopause
Typical Length of Menses (Days You Bleed)
Typical Length of Cycle (From the 1st Day of One Cycle to 1st Day of the Next)
Number of Pregnancies
Number of Births
Number of Abortions
Number of Miscarriages
Hysterectomy
Yes
Partical
Complete
No
Check all that apply to you
Scanty Flow
Painful Periods
Low Libido
Heavy Flow
Breast Tenderness
Excessive Libido
Clotting
Breast Lumps
Painful Intercourse
Vaginal Discharge
Nipple Discharge
Infertility
Abnormal Pap Smear
Fibrocystic Breasts
Fibroids
Menopausal Symptoms
Bleeding Between Cycles
Endometriosis
Premenstrual Problems
Irregular Cycles
Ovarian Cysts
Men Only
Check all that apply
Low Libido
Seminal Emissions
Prostate Problems
Excessive Libido
Premature Ejaculation
Testicular Pain
Impotence
Painful Intercourse
Testicular Redness
Vasectomy
Testicular Swelling
Other
If other please specify
Medications
Please list medications, herbal supplements and vitamins you are currently taking:
Drug / Supplement / Vitamin - Reason For Taking - For How Long - Dosage - Frequency
Lifestyle
How would you rate the following areas of your health in the past month.
Digestion
Great
Good
Fair
Poor
Comments
Stool
Great
Good
Fair
Poor
Comments
How many times per day?
Do they feel complete?
Yes
No
Stool consistency?
Loose
Formed
Hard to Pass
Other
If other please specify
What is the color of your stools?
Is there blood in your stools?
Yes
No
If yes how often?
Urination
Great
Good
Fair
Poor
Comments
How many times per day?
What color is your urine?
After you've gone to sleep do you get up to urinate?
Yes
No
How often?
Is your urination painful?
Yes
No
Appetite
Great
Good
Fair
Poor
Comments
Diet
Great
Good
Fair
Poor
Comments
Are you vegetarian or vegan?
Yes
No
For how long?
Foods you crave
When?
Daily water intake
Daily soda intake
Caffeine?
Yes
No
Daily coffee intake?
Caffeine?
Yes
No
Daily tea intake?
Caffeine?
Yes
No
Do you drink alcohol?
Yes
No
How Often
What kinds?
Past Use?
Yes
No
Date Stopped
Yes
No
Do you use tobacco?
Yes
No
Past Use?
Yes
No
Date Stopped
Yes
No
Do you use recreational drugs?
Yes
No
Past Use?
Yes
No
Date Stopped
Yes
No
How do you feel about the following areas of your life in the past month.
Energy
Great
Good
Fair
Poor
On a scale of 1 to 10 (10 is high energy)
Comments
Sleep
Great
Good
Fair
Poor
Hours per night
Do you wake up feelign rested?
Yes
No
Comments
Sex Life
Great
Good
Fair
Poor
N/A
Comments
School
Great
Good
Fair
Poor
N/A
Comments
Exercise
Great
Good
Fair
Poor
How often?
What kind?
Comments
How would you rate your stress level on a scale of 1 to 10? (10 is high stress)
How well do you feel you handle your stress?
Great
Good
Fair
Poor
Pain
Areas of pain
How long have you had this pain
Describe the onset of your pain
On a scale of 1-10 (10 being worst) how strong is your pain
What does your pain feel like? (check all that apply)
Dull 6 Sharp
Stabbing
Sore
Achy
Cramping
Burning
Constant
Comes and Goes
Fixed
Moves About
Does the pain radiate?
Yes
No
Where
What aggravates the pain?
Ice
Heat
Rest
Movement
Pressure
Moisture
Massage
Nothing
Other
If other please list
What helps the pain?
Ice
Heat
Rest
Movement
Pressure
Moisture
Massage
Nothing
Other
If other please list
Does anything relieve this pain? (i.e.; medications, over the counter drugs, liniments)
Other treatments you have had for this pain
Anything you wish to add?
The above information is true to the best of my knowledge.
Signature
Date
MM slash DD slash YYYY
