Health History Questionnaire Lisa Desrosiers M Ac L Ac 278 Elm Street

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Health History Questionnaire Lisa Desrosiers M Ac L Ac 278 Elm Street Powered By Docstoc
					Lisa Desrosiers, M.Ac., L.Ac.                                                                      278 Elm Street, Suite 227
Licensed Acupuncturist                                                                                Somerville, MA 02144                                                                                617-548-8167

                              Confidential Health History Questionnaire
Name:                                                                                               Date:
Home Phone:                                    Cell Phone:                                    Work Phone:
Email:                                         Date of Birth:                   Age:          Gender:
Best way to contact you:                                      Is it ok to leave messages?
Employment status: Full–time / Part–time / Student / Other (describe:)
Occupation:                                    Employer:                               Address:
Emergency Contact:                                       Phone:                               Relationship to you:
Status:     Single/ Married/ Living with Partner/ Divorced/ Widowed/ Separated          Children: Yes / No Ages:
How did you hear about us?                                                      Have you had acupuncture before? Yes/ No
Primary Care Physician:                                                         Street Address:
City, State, Zip:                                                               Phone:

Main Problems/Reasons for Visit                            Additional issues you would like to address
1.                                                         1.
2.                                                         2.
3.                                                         3.
4.                                                         4.

What is the main issue you would like to focus on today?

When did this problem begin? (Please be specific)

What do you think caused it? Is the cause still present?

What treatments have you tried already? What were the results?

Have you been given a diagnosis for this problem? If so, what?

To what extent does this problem interfere with your daily activities? (work, sleep, eating, sex...)

How severe is your problem right now? (Please mark the scale below)

No problem                                          Moderate                                           Worst Imaginable

What’s the most severe level you have endured within the last week? (Please mark the scale below)

No problem                                    Moderate                                                 Worst Imaginable
What are your treatment goals?  Temporary relief of symptoms/pain control
                                    Eliminate root or cause of problem (if possible)
                                    Lessen/eliminate habits which caused the condition or made it worse
                                    Maintenance care (periodic balancing/tune-up to keep in good health)
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Current Medication                            Dose per day      For how long?             For What Condition?

Herbs, Vitamins and Supplements               Dose per day     For how long?             For What Condition?

   Past Medical History (please indicate by date(s):
      Cancer                    High Blood Pressure                   Rheumatic Fever                 Venereal Disease
     Diabetes                         Heart Disease                           Seizures                         Asthma
     Hepatitis                               Stroke                    Thyroid Disease                     Pacemaker
   Surgeries (type and date):

   Significant Trauma (auto accidents, falls, etc., include dates):

   Significant Dental Work (type and date):

   Birth History (prolonged labor, forceps delivery, caesarian section, other):

   Allergies (drugs, chemicals, foods, animals):

   Family Medical History
    High Blood Pressure                      Alcoholism                   Cancer:                      Allergies:
    Heart Disease                            Seizures
    Arteriosclerosis                         Asthma
    Stroke                                   Diabetes

                                                                       On the following page, please check boxes of
                                                                       any symptoms you have had in the past 2-4 weeks.

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          General                Color blindness                   Gastrointestinal            Heavy periods
                                 Blind field                                                   Light periods
 Chills                         Spots in front of eyes
                                                                   Bad breath
                                                                                                Painful periods
 Fevers                         Eye pain
                                                                   Nausea
                                                                                                Irregular periods
 Sweat easily                   Eye strain
                                                                   Vomiting
                                                                                                Changes in body/psyche
 Night sweats                   Cataracts
                                                                   Heartburn                    prior to menstruation
 Localized weakness             Eye Dryness
                                                                   Belching                   Clots
 Bleed or bruise easily         Excessive tearing
                                                                   Indigestion                Vaginal discharge:
 Peculiar tastes or smells      Discharge from eyes
                                                                   Diarrhea                   Menopause:
 Strong thirst (cold / hot)     Poor hearing
                                                                   Constipation                 Age:
 Thirst, no desire to drink     Ringing in ears
                                                                   Chronic laxative use         Year:
 Fatigue                        Earaches
                                                                   Blood in stools            Postcoital bleeding
 Sudden energy drop             Discharge from ear
                                                                   Black stools               Vaginal sores
    Time of day:__________                                         Abdominal pain/cramps      Breast lumps
                                 Nose bleeds
 Edema                                                            Gas                        Nipple discharge
                                 Sinus congestion
                                 Nasal drainage
                                                                   Rectal pain               Do you practice birth control?
   Poor sleeping                                                  Hemorrhoids                      Yes  No
   Tremors
                                 Grinding teeth
                                                                Other stomach or intestinal   What type and for how long?
   Poor balance
                                 Teeth problems
                                 Jaw clicks                                                  _____________________
   Cravings                                                    _____________________
                                Concussions
    Change in appetite
                                 Recurrent sore throats                                          Musculoskeletal
   Poor appetite
                                 Hoarseness
                                                                     Genito-Urinary             Neck pain
   Weight change
                                                                   Pain on urination
    Gain / Loss ___________      Sores on lips/tongue                                          Shoulder pain
                               Other head / neck problems          Urgency to urinate          Back pain
                                                                   Frequent urination          Elbow pain
      Skin and Hair                Cardiovascular
                                                                   Blood in urine              Hand/wrist pain
  Rashes                                                          Decrease in flow            Hip pain
  Itching
                                  High blood pressure             Dribbling                   Knee pain
  Change in hair or skin
                                  Low blood pressure              Kidney stones               Foot/ankle pain
  Ulcerations
                                  Chest discomfort/pain           Impotency                   Muscle pain
  Eczema
                                  Heart palpitations              Change of sexual drive      Muscle weakness
  Hives
                                  Cold hands or feet              Sores on genitals         Other pain? ____________
  Pimples
                                  Swelling of hands            Do you wake to urinate?       _____________________
  Recent moles
                                  Swelling of feet                    Yes  No
  Loss of hair
                                  Blood clots                  How often? ____________         Neuropsychological
                                  Fainting                     What color is your urine?
  Dandruff
                                                                _____________________             Seizures
Other hair or skin problems       Difficulty in breathing
                               Other heart/blood vessel         Other genital or urinary          Areas of numbness
                               problems: ______________         system problems?________          Weakness
                                                                _____________________             Sleep disorder
                                      Respiratory                                                 Concussion
    Head, Eyes, Ears                                                Pregnancy and                 Violence potential
    Nose, and Throat            Cough                                                            Vertigo
                                Asthma/wheezing                     Gynecology                   Lack of coordination
 Dizziness                     Difficulty in breathing when   # of pregnancies:                 Bad temper
 Migraines                       lying down                    # of births:                      Depression
 Headaches                     Phlegm Color?________          # premature births:               Easily stressed
 When:_____________             Coughing blood                 # of miscarriages:                Loss of balance
 Where: ____________            Pneumonia                      # of abortions:                   Poor memory
 Facial pain                   Bronchitis                     Age at first menses:              Anxiety
 Glasses                      Other lung problems:______       Length of full cycle:             Substance abuse
 Poor vision                  ______________________           Length of menses:             Have you ever been treated
 Night blindness                                               Last menses start date:       for emotional problems?
 Blurry vision                                                                                       Yes  No

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Last Physical        Date: ________ Doctor: ________________________ Results: ____________________

Lifestyle/Self-care          Please indicate below:
                                                 Yes          No          Amount/How often (Please describe)
Have you ever smoked cigarettes?                             
Do you currently smoke cigarettes?                           
Do you drink alcohol?                                        
Do you use recreational drugs?                               
Previous drug/alcohol issues?                                
Do you drink caffeinated beverages?                          
Do you exercise regularly?                                   
Do you have food cravings?                                   
Are there foods you need to avoid?                           
What type of stress do you have in your life? (chemical, physical, psychological, etc.):

Have there been any major stressors in the past 6 months? (describe)
How would you describe your energy level?
How would you describe your sleep?
Do you enjoy your job?                                                        How often do you work?
How do you relax or unwind?
How is your home life?
How do you tend to become imbalanced when overtired or under stress?

Diet    Please give a general description of the food you eat during a “typical” day.
       Before bed:
  Between meals:

Are you now, or have you ever been, on a restricted diet? Please describe the diet and give the start/stop dates:

Health Insurance Information:
Plan Name: ________________________ Plan #: _________________________________
Insured Name: _____________________________________________

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