Patient Medical History Intake Form printable pdf download

PATIENT MEDICAL HISTORY INTAKE FORM

Patient Name: ____________________________________________

Date: __________________________

Date of Birth: ______________________________________________

Medical History:

(Please check box if you have ever had the following)

� arthritis

� kidney or bladder problems

Primary Health Concerns: _________________________________

� asthma

� gallstones

� bronchitis

� ulcers

__________________________________________________________

� pneumonia

� gastric reflex

� allergies

� eating disorder

__________________________________________________________

� anemia

� high blood pressure

� heart problems

� chronic fatigue

__________________________________________________________

� chronic pain

� hepatitis

� migraine headache

� alcoholism

__________________________________________________________

� eye disorder

� substance abuse

� cancer

� jaundice

Secondary Health Concerns: ______________________________

� diabetes

� female reproductive disorders

� epilepsy

� sudden weight loss

__________________________________________________________

� stroke

� sudden weight gain

__________________________________________________________

Family History:

(Please list any major medical conditions that your

parents have or had that you know of)

Date of onset of symptoms: _______________________________

__________________________________________________________

Pain from this condition is: � minimal

� moderate

� slight

� severe

__________________________________________________________

Have you had this condition in the past? ___________________

__________________________________________________________

What makes it better? _____________________________________

Are your currently receiving care from:

� chiropractor

� massage therapist

What makes it worse? _____________________________________

� medical specialist

� nutritionist

� physical therapist

� therapist

Is your condition: � getting worse � comes and goes

� constant

� don’t know

Have you had acupuncture before? Yes

Medications you are currently taking: ______________________

If yes, for what condition? ___________________________________

__________________________________________________________

Do you use any of the following?

� Alcohol

Amount/Wk ______________________________

__________________________________________________________

� Tobacco

Amount/Wk ______________________________

� Coffee

Cups/Day _______________________________

List surgeries/procedures: ________________________________

� Carbonated sugar drinks (Pepsi, Coke, etc.)

Servings/Day ____________________________

__________________________________________________________

� Foods labeled “Diet”

� Processed Foods

__________________________________________________________

How many glasses of water do you drink per day? __________

Have you been injured in an accident? Yes

What exercise do you do on a regular basis?

If yes, please describe: _____________________________________

� walking

� gym workout/training

� jogging

� exercise classes

__________________________________________________________

� bicycle

� yoga

� hiking

� Pilates/Core/Barre

Date of last physical exam: ________________________________

� rowing/kayaking

� dance

� sports

� other ________________________

Please complete reverse

Acupuncture Arts East

62 Brown Street, Merrimack Medical Center, Suite 402, Haverhill, MA 01830

t: 978-372-4771

Patient Medical History Intake Form

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