Millie Heimlich, L.Ac.
630.606.6636 MAHeimlich@gmail.com
This is a CONFIDENTIAL questionnaire and will be used solely for purposes of diagnosis and treatment.
It will not be shared with or distributed to any outside sources.
Please fill it out completely. If you have any questions, please ask.
Personal Information
Name Date
Address City State Zip
Home Phone Cell Phone email
Reminder preference: Home Phone Cell Phone email Other
Yes you may contact me, but only at the following number(s)
Marital Status Married Single Divorced Widowed Number of Children
Occupation Employer
Work Phone Personal Responsible for your account
Emergency Contact
Who can we thank for referring you to this office?
Health History
Age Birth date / / Gender Height Weight
Have you received acupuncture therapy before? Yes No
When? With Whom?
Please indicate the use, quantity and frequency of the following:
This is confidential and nonjudgmental. Yes No Describe Quantity/
Be honest ☼ Frequency
Caffeinated Beverages
Recreational Drugs
Tobacco
Alcohol
Water Intake
Soda
Updated 2/19/2012
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Millie Heimlich, L.Ac.
630.606.6636 MAHeimlich@gmail.com
Please indicate a family history of the following conditions:
_______ I am adopted
You Relative Date You Relative Date
Cancer Rheumatic Fever
Hepatitis Infectious Diseases
High Blood Emotional
Pressure Disorders
Stroke Heart Disease
Neurological Gall Bladder
Disease Disease
Thyroid Disease Seizures
Alzheimer’s Tuberculosis
Diabetes Other:
Please check any
that apply AIDS Gonorrhea Syphilis HIV Chlamydia Herpes Hepatitis
TB
Please list any herb, drug or food
allergies
Please list all medications (prescribed and OTC)/ herbs/ vitamins and supplements which you are
currently taking:
Type Dose Reason Date Prescribed by Date of last
Prescribed Prescribed Check up
Please list any implanted
devices (pacemakers,
titanium, etc.)
Updated 2/19/2012
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Millie Heimlich, L.Ac.
630.606.6636 MAHeimlich@gmail.com
What are the main health problems for which you are seeking treatment?
What other forms of treatment have you sought?
Past Medical History (Prior illness, injury, hospitalization, Date Occurred
surgery, trauma)
Lifestyle History
How do you feel about the following areas in your life?
Please check the appropriate boxes and indicate any problems you may be experiencing:
Great Good Fair Poor Bad Comments
Significant Other
Family
Diet
Sex
Self
Work
Spirituality
Have you had any major stresses in the last 6 months regarding:
Money Job Relationship Home life Children
Other
Updated 2/19/2012
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Millie Heimlich, L.Ac.
630.606.6636 MAHeimlich@gmail.com
Yes No Comments
Do you exercise regularly?
Do you allow time to unwind and Relax?
Do you manage stress well?
Do you sleep soundly?
Do you eat healthy foods?
Do you eat three meals per day?
Are you or have you been on any type of diet?
Do you obsess about food?
Do you have any food allergies?
Do you have any particular food cravings?
Typical
Breakfast
Typical
Lunch
Typical
Dinner
Typical
Snacks
Health Information for Women Only
Are you Yes No # of # of live # of # of
pregnant? pregnancies births miscarriages abortions
Ever been Fibroids Fibrocystic Endometrio Ovarian PID Other
diagnosed w/: Breasts sis Cysts ____________
Age of 1st Period Number of days Number of days
(menarche) between periods of flow
Color of Flow Do you have clotting? Yes No Color of clots
Average # of pads or 1st 2nd 3rd 4th Additional
tampons used: Day Day Day Day Days
Updated 2/19/2012
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Millie Heimlich, L.Ac.
630.606.6636 MAHeimlich@gmail.com
Do you experience any pain during your menstrual cycle? Other symptoms related to
menstrual cycle:
Nature of Time pain occurs (before, Location of Pain Please check all that apply:
Pain during, or after flow)
Before During After Lower Discharge Hot flashes
Abdomen
Constant Lower Nausea Decreased
Back libido
Intermittent Thighs Swollen Headache
breasts
Cramping Other: Poor Diarrhea
_______________ appetite
Burning Increased Ravenous
libido appetite
Stabbing Vaginal Night
dryness sweats
Aching Constipation Insomnia
Dull Mood Bearing
swings down
sensation
Date of last Age of last period
gynecological exam (Menopause)
Lab Results: Symptoms related to Menopause:
Bone Density Scan Normal Abnormal Hot flashes Insomnia
Pap Smear Normal Abnormal Night sweats Vaginal
dryness
Mammogram Normal Abnormal Digestive Changes Mood
swings
Explanation: Changes in libido Discharge
Changes in Headaches
appetite
Health Information for Men Only
Date of last prostate PSA Manual prostate
check up: results: exam results:
Lab
results:
Frequency of Daytime Nighttime Color of Odor:
urination: urine: Clear Murky
Updated 2/19/2012
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Millie Heimlich, L.Ac.
630.606.6636 MAHeimlich@gmail.com
Symptoms related to
prostate:
Prostate Delayed Dribbling Incontinence Retention of
Problems stream Urine
Rectal Increased Decreased Premature Impotence
dysfunction libido Libido ejaculation
Back pain Groin pain Testicular Other
pain
Symptoms Survey
Presently Had in Presently Had in
Have Past Have Past
Lack of appetite Hemorrhoids
Excessive appetite Blood in stool
Loose stools or diarrhea Wear glasses
Abdominal cramping Blurred vision
Indigestion Double vision
Nausea Cataracts
Vomiting Glaucoma
Belching, burping Eyes feel swollen
Heartburn, reflux Pressure in eyes
Bloating, gas Eye pain
Fatigue Eye tiredness/strain
Easily bruised Seeing spots
Weight gain Sensitivity to light
Weight loss Eye dryness
Excessive thirst Eye redness
Abdominal pain Eye itchiness
Alternating diarrhea & Eye tearing
constipation
Sore gums Jaundice (yellowish eyes
or skin)
Bleeding gums Difficulty digesting oily
foods
Mouth dryness Gall stones
Bad taste in mouth Light colored stools
Bad breath Soft or brittle nails
Insomnia High cholesterol levels
Heart palpitations Muscle pain
Nightmares Muscle spasm or twitching
Mentally restless Sciatica
Irregular heartbeat Easily angered or
agitated
Updated 2/19/2012
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Millie Heimlich, L.Ac.
630.606.6636 MAHeimlich@gmail.com
Chest pain Difficulty making plans or
decisions
Heart attack Date Cold hands and feet
Occurred_______________
Poor circulation Hearing difficulties
High blood pressure Ringing in ears
Low blood pressure Ear pain
Dizziness Ear infections
Sore tongue Kidney stones
Numbness of tongue Decreased sex drive
Cough Hair loss
Cough with blood Frequent Urination
Shortness of breath Excessive urination
Decreased sense of smell Nighttime urination
Nose bleeds Unable to hold urine
Nasal polyps Burning on urination
Nasal or sinus congestion Difficult urination
Sinus infections Painful urination
Seasonal allergies Blood in urine
Asthma Bladder infections
Hay Fever Joint Pain
Where___________________
Frequent colds Neck Pain
Intolerance to weather Back pain
changes
Bronchitis Knee problems
Pneumonia Teeth grinding
Lack of perspiration Anxiety
Excessive perspiration Depression
Dandruff Problems with alcohol or
drug use
Eczema Seizures
Psoriasis Concussion
Other skin problems Headaches
____________________
Colitis or diverticulitis Cysts/Tumors
Constipation
Updated 2/19/2012
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Millie Heimlich, L.Ac.
630.606.6636 MAHeimlich@gmail.com
Name Date
Are there any issues of physical/sexual/emotional abuse that you would like to discuss?
__ Yes __No
The above information is accurate and true to the best of my knowledge. I understand that an
acupuncture appointment could include acupuncture, herbal remedies, dietary counseling,
Asian Body Therapy, cupping, gua sha, moxibustion, and use of liniments or essential oils.
I take responsibility for alerting my practitioner to any physical, mental, or emotional changes that
occur with my health. I also understand that cancelled or missed appointments without 24 hours
notice will be charged half of the price of the missed session.
Signature: _________________________________________________________________
Date:_________________________________
Updated 2/19/2012
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