Mikhael Rosenberg, L.Ac.
Health History Questionnaire
All questions are strictly confidential and will become part of your medical record.
Patient Information
Name: _______________________________________________ Date of Birth: ___/___/_____
Address: _____________________________ City: _____________________ State: _________
Zip: _________ Email: ___________________________________________________________
Phone number: Home (_____)_____-_________ Cell: (_____)_____-_______
In emergency notify (name): ________________________________ Phone: (_____)_____-_______
Height: ________ Weight: ________ Age: ______ Sex: Male Female
Occupation: _____________________________ Employer: _____________________________
Chief Complaint
Reason for your treatment today: _____________________________________________________
______________________________________________________________________________
Are you being treated for this condition by anyone else: Yes No
If Yes, who? ____________________________________________________________________
Have you seen a physician? Yes (Diagnosis:__________________________________) No
How else have you managed it? _______________________________________________________
Have these treatments helped? Yes Somewhat Not much Not at all
How long have you had this condition? _________________________________________________
How does this condition affect you? ___________________________________________________
Rate the intensity of Physical Discomfort associated with the complaint.
(None) 0 1 2 3 4 5 6 7 8 9 10 (Unbearable)
Rate the intensity of Emotional Discomfort associated with the complaint.
(None) 0 1 2 3 4 5 6 7 8 9 10 (Unbearable)
Are there any other concerns you would like to be treated for? No If Yes, please describe:
______________________________________________________________________________
______________________________________________________________________________
Use the models below to indicate the location of any discomfort.
Please shade in the areas where you feel symptoms associated with your complaint.
If you are experiencing any pain, how would you rate it by using the scale below:
Location Pain Value (0-10) Date of Onset
________________________ _______________ _________________
________________________ _______________ _________________
________________________ _______________ _________________
Does the pain radiate? No Yes, where? __________________________________________
What helps the pain? Ice Heat Rest Movement Pressure Moisture Massage
Other: ______________________________________________________
What aggravates the pain? Ice Heat Rest Movement Pressure Moisture Massage
Other: ______________________________________________________
Medical History
Circle any problem, disease, or symptom you have now.
√ Check off items that affected you in the past.
Cardiovascular Conditions: Emotional / Mental: Energy & Immunity: Respiratory:
Heart Disease Depression Chronic Fatigue Syndrome Pneumonia
A Pacemaker ADD or ADHD General Fatigue Asthma
High Blood Pressure Schizophrenia Slow Wound Healing Frequent Common Colds
Low Blood Pressure Mood Swings Easy Bruising Difficulty Breathing
Chest Pain Panic Attacks Chronic Infections Emphysema
Palpitations Nervousness Frequent Allergies Persistent Cough
Varicose Veins Anxiety Pleurisy
Edema Alzheimer’s Tuberculosis
Dementia Shortness of Breath
Musculo-Skeletal: Head, Eye, Ear, Nose & Throat: Genito-Urinary Tract: Neurological:
Neck / Shoulder Pain Impaired Vision Kidney Disease Vertigo / Dizziness
Muscle Spasms / Cramps Eye Pain/Strain Kidney Stones Paralysis
Arm Pain Glaucoma Painful Urination Numbness / Tingling
Upper Back Pain Glasses / Contacts Dribbling Urination Loss of Balance
Mid Back Pain Tearing / Dryness Frequent UTI Seizures / Epilepsy
Low Back Pain Impaired Hearing Frequent Urination Dyslexia
Leg Pain Ear Ringing Blood in Urine Stroke
Osteoporosis Earaches Discharge Date:_____________
Joint Pain Ear Infections Incontinence details:__________________
Arthritis Headaches ______________________
details:____________________ Sinus Problems ______________________
________________________ Nose Bleeds
________________________ Teeth Grinding
Frequent Sore Throats
TMJ / Jaw Problems
Hay Fever
Gastrointestinal: Endocrine: Other: Men Only:
Stomach Ulcers Hypothyroid Cancer Impotence
Changes in Appetite Hypoglycemia Type:_____________________ Vasectomy
Nausea / Vomiting Hyperthyroid ________________________ Date:____________
Abdominal Pain Diabetes Type I Fibromyalgia Prostate problems
Passing Gas Diabetes Type II Lupus Testicular Pain /
Heart Burn Night Sweats Candida Redness / Swelling
Belching Unusual Sweating Anemia Low libido
Gall Bladder Disease Feeling Hot or Cold Rashes Excessive libido
Gall Bladder Stones Eczema / Hives Painful Intercourse
Hemorrhoids Cold Hand / Feet Seminal emissions
Constipation Hemophilia Premature ejaculation
Diarrhea Thin / Graying hair Erectile Dysfunction
Irritable Bowel Syndrome Hepatitis
Women Only: Are you pregnant right now? Yes No Trying Maybe Method of Birth Control (if any): ____________
Age at first period: _______ Date of last menses: ________ Age at menopause: _______
Typical length of menses (days): ______ Typical length of cycle (from 1st day to 1st day of menses): ______
Number of: Pregnancies: Births: ____ Abortions: ____ Miscarriages: ____ Hysterectomy: Yes, date:________ No
Check all that apply: Low libido Excessive libido Painful Intercourse Clotting Painful Periods Heavy Flow
Scanty Flow Bleeding Between Cycles Irregular Cycles Vaginal Discharge Breast Lumps / Tenderness
Nipple Discharge Infertility Menopausal Symptoms Premenstrual Problems Abnormal Pap Smear
Endometriosis Fibroids Fibrocystic Breasts Ovarian Cysts Other: ___________________________________
Surgical History:
_________________________________________________ Date: ______________________
_________________________________________________ Date: ______________________
_________________________________________________ Date: ______________________
Please list all prescription and over the counter medications you are currently taking:
Drug Name Reason for taking Dose Frequency
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
I am taking Coumadin/ Warfarin/ or any other blood thinning medicine: Yes No
Please list all supplements and herbs you are currently taking:
Supplement Reason for taking Frequency
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
List allergies to medications, chemicals or foods: ________________________________________________
____________________________________________________________________________________
Do you currently have any infectious diseases? Yes No Possibly
If yes, please identify: ______________________________________________________________
Family History
Please check any of the conditions that apply to your family members listed below.
Condition Mother Father Sibling Maternal Gparent Paternal Gparent
Heart disease
Cancer
Hypertension
Stroke
Asthma
Allergies
Migraines
Depression
Other mental illness
Substance abuse
Osteoporosis
Diabetes
Glaucoma
Lifestyle
Tobacco: Yes No Amount: _________ Alcohol: Yes No Amount: _________
Coffee: Yes No Amount: __________ Recreational Drugs: Yes No
Do you feel you are at or near your ideal weight? Yes No
Do you feel you have enough energy? Yes No
Best time of day: ________________ Worst time of day: _________ Favorite Season: _____________
Hours of sleep / night: _________ Do you feel rested after a nights sleep? Yes No
Typical day’s meals:
Breakfast: ____________________________________________________________________________
Lunch: _______________________________________________________________________________
Dinner: ______________________________________________________________________________
Snacks / Other: _______________________________________________________________________
Food cravings: _________________________________________________________________________
Are you vegetarian or vegan? Yes No List any other special diets: ____________________________
How would you rate your current stress level? Very High High Moderate Low
Did you feel safe and nurtured as a child? Always Usually Sometimes Never
What would you characterize as your predominate emotion right now? Anxiety Worry Anger Grief
Fear Depression Melancholy Happiness Contentment Joy Numbness / Apathy
Other: _____________________________________________________________________________
If you were guaranteed of success and money and time were not obstacles, what would you like to do with your life?
____________________________________________________________________________________
Please feel free to express any concerns or thoughts that are relevant to your health here:
____________________________________________________________________________________
____________________________________________________________________________________
The above information is true to the best of my knowledge. I understand and accept that I am responsible for full
payment of my account and that payment is expected at the time of service. I also understand and accept that I am
expected to notify Mikhael 24 hours prior to any cancellations or changes to my appointment times and that if I do
not I may be charged for the appointment.
X Sign: ___________________________________________________________ Date: ____________
Parent / Guardian (if applicable)___________________________________________