Health History Questionnaire
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4Health History Questionnaire
DATE: _______________
Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All of your
answers will be held absolutely confidential. If you have any questions, please ask. If there is anything you wish to bring to
our attention, which is not asked on this form, please note it in the comments section. Thank you.
N
: (F
)
(M
I
)
(L
)
H
P
:
AME
IRST
IDDLE
NT
AST
OME
HONE
O
R
Cell Phone:
A
:
W
P
:
DDRESS
ORK
HONE
C
:
S
:
Z
:
O
:
ITY
TATE
IP
CCUPATION
P
B
:
D
B
:
A
:
S
:
H
:
W
:
M
S
:
LACE OF
IRTH
ATE OF
IRTH
GE
EX
T
T
ARITAL
TATUS
F
P
:
P
:
AMILY
HYSICIAN
HONE
I
E
N
:
P
:
N
MERGENCY
OTIFY
HONE
R
B
:
EFERRED
Y
I
C
:
P
#:
NSURANCE
O
OLICY
H
?
AVE YOU EVER BEEN TREATED BY ACUPUNCTURE OR ORIENTAL MEDICINE BEFORE
Main problem(s) you would like us to help you with:
How long ago did this problem begin (be specific)?
To what extent does this problem interfere with daily activities (work, sleep, sex)?
Have you ever been diagnosed for this problem? If so, what?
What kind of treatments have you tried?
Past medical history (please include dates):
Significant Illnesses:
Cancer
Diabetes
Hepatitis
High Blood Pressure
Heart Disease
Rheumatic Fever
Thyroid Disease
Seizures
Venereal Disease
Other:
Surgeries:
Significant Trauma (auto accident, falls, etc.):
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Parent category: Life