Health History Questionnaire


1- Personal Information


2- General Health History

Please fill out the following information as completely as possible.

Describe your main health concerns along with any diagnoses you have been given:


Rate the following symptoms that you have experienced on a scale from 1-10: (10 being worst).

Visual problems / floaters

Blurred vision / poor night vision

Red / dry / itchy eyes

Headaches / migraines

Dizziness

Muscle twitching / spasm

Neck / shoulder tension

Brittle nails

PMS
Genital itching / pain / rashes

Discharge from nipples

Irritability / frustration / impatience

Depression

Stress

Emotional eating

Unfulfilled desires

Sighing

Feeling of lump in throat

Sensation or pain under rib cage

------------


Palpitations

Chest pain / tightness

Insomnia / Sleep problems

Forgetful

Aversion to heat

Bitter taste in mouth

Tongue / mouth ulcers / cankers

Restless / easily agitated

Anxiety

Vivid dreams

Lack of joy in life

------------


Frequent urination

Bladder infection

Lack of bladder control

Wake to urinate

Feel cold easily

Cold hands / feet

Night sweats / hot flushing

Vaginal dryness

Low sex drive

High sex drive

Loss of head hair

Hearing problems

Crave salty food

Poor long term memory

Ankle swelling

Tinnitus

Fear
Dry cough

Cough with phlegm

Nasal discharge / drip

Sinus infection / congestion

Itchy / painful throat

Dry mouth / throat / nose

Skin rashes / hives

Snoring

Shortness of breath

Allergies / asthma

Weak immune system

Alternate fever / chills

Grief / sadness

------------


Heaviness in the head / body

Fatigue

Difficult getting up in morning

Water retention

Muscular tired / weak

Bruise easily

Unusual bleeding (stool, nose, etc)

Bad breath

Poor appetite

Increased appetite

Crave sweets

Poor digestion

Nausea / vomiting

Bloating / gas

Hemorrhoids

Constipation

Loose stool

Alternate constipation / loose

Abdominal pain

Intestinal pain / cramping

Heartburn

Overweight

Reoccurring yeast infections

Aversion to cold / wind (ex: air conditioning)

Cold nose

Increased thirst

Prefer warm / cold drinks

Sweat easily

Foggy mind

Pensive / over-thinking



Please describe any other symptoms that you feel may be important for us to know about:


List medications/supplements/vitamins/herbs taken in past 6 months (include reason taken, dose & duration:



3- Lifestyle
Do you have exposure to heat on a regular basis (sauna, Jacuzzi)? YN
If Yes please describe:


Do you or have you had exposure to chemicals or X-rays? YN
If Yes please describe:


Do you have allergies (seasonal, food, chemical, drug)? YN
If Yes please describe:


Do you drink caffeine? YN
If Yes what kind and amount per day/week:


Do you or have you smoked cigarettes? YN
If Yes amount per day/week:


Do you drink alcohol? YN
If Yes amount per day/week:


Do you use marijuana? YN
If Yes amount per day/week:


Do you exercise? YN
If Yes what kind and amount per day/week:


Do you use drugs (recreational)? YN
If Yes what kind and amount per day/week:



Do you aspire to follow a particular diet plan? YN
If you answered Yes please describe:


Please describe your average daily diet (be as specific as possible):



4- Family History
Are you aware of any family history of hereditary, genetic, or reproductive disorders? YN
If you answered Yes please describe



5- In addition to acupuncture I am interested in receiving
YESNO

YESNO

YESNO


6- Female Reproductive History
Have you been diagnosed with any of the following:

YN
YN
YN
YN
YN
YN
YN
YN



If you are trying to conceive, when did you start actively trying:



BBT Temperature charting YES



NormalAbnormal


Hysterosalpingogram (HSG) YES



NormalAbnormal


Hysteroscopy YES



NormalAbnormal


Laparoscopy YES



NormalAbnormal


Semen Analysis YES



NormalAbnormal


Anti-Sperm Antibody YES



NormalAbnormal


Day 3 FSH YES



NormalAbnormal


Day 3 Estradiol YES



NormalAbnormal


AMH YES


åç
NormalAbnormal


LH YES



NormalAbnormal


Progesterone YES



NormalAbnormal


Prolactin YES



NormalAbnormal


Antral Follicle Count YES



NormalAbnormal


Thyroid tests YES



NormalAbnormal


Testosterone YES



NormalAbnormal


Immunology testing YES



NormalAbnormal


-----

Please list any assisted reproductive procedures starting with the most recent (ex: Egg Retrieval, FET, medicated IUI, or un-medicated IUI).

If applicable, please include the number of embryos frozen, genetically tested, and transferred under outcomes.




Age of first menstrual cycle:


Date of onset of last menstrual cycle:


Are your cycles regular:
YN

Cycle length (number of days from the start of one cycle to the start of the next):

If you have regular cycles what day do you usually ovulate on:

How do you track ovulation (ovulation predictor kit, increased vaginal fluid):

Do you notice stretchy, clear, vaginal discharge before ovulation:

Amount of flow (Spotting, Light, Moderate Heavy) on each cycle day (ex: SLMML)

What color is your menstrual blood (ex: pink, bright red, brown, purple, black):

Do you have clots (tissue in menstrual flow).
If Yes what size (ex: almond, egg yolk):
nonemild (grain of rice size)moderate (almond size)severe (egg yolk size)

Symptoms around menses: (ex: Breast changes, Irritability, Fatigue, Bowel changes, Low back pain, Cramps). Please indicate if symptoms occur before or after the start of your flow.


Have you ever used hormonal contraception (ex: birth control, Mirena, NuvaRing, medicated IUD)?
YN

If Yes for how many years and when did you discontinue:


Have you been pregnant before:
YN

How long did it take to conceive:

If applicable, list pregnancies starting with the most recent:



7- Male Reproductive History
Numer of pregnancies with current partner:


Number of pregnancies with previous partner(s):


Age(s) of children, if any:


How long have you been trying to conceive:
Months

Years

Have you ever had any of the following:
Undescended testicles: YN
Injury to the testicles: YN
Hernia repair: YN
Varicocele: YN
Vasectomy: YN
Bladder or prostate issues/surgery: YN
Epididymitis: YN
Urinary tract infection: YN
Sexually transmitted disease: YN
Problem achieving erections: YN
Problems with ejaculation: YN
Problems with sex drive: YN
Abnormal sexual development: YN
Fever within the last 3 months: YN
Family member with fertility problems: YN
Early puberty (before 12 yrs): YN
Late puberty: YN
History of mumps: YN
Neurological problems: YN
Hormonal problems: (thyroid,diabetes,etc.)YN

Please list any surgeries you have had other than those listed above:



Comments on any of the above:



8- Informed Consent

I, do hereby request and give permission to receive acupuncture from Sage Acupuncture LLC, and any affiliated Licensed Acupuncturist. Oriental Medical treatments include various modalities including but not limited to acupuncture, herbal, and dietary supplements. I understand that I have the right to inquire about and refuse any part of the treatment.

I understand and am informed that, as in allopathic medicine, in the practice of Oriental Medicine there are some risks of treatment. I understand that although these risks are unlikely to occur, they are possible. These risks include but are not limited to: bleeding, bruising, nerve damage, punctured organ, aggravation of symptoms, the appearance of new symptoms, fainting, and fatigue. I do not expect the practitioner to be able to anticipate and explain all risks and complications. I wish to rely on the practitioner to exercise their best judgment. Although I am aware that acupuncture and the other procedures used in Oriental Medicine have helped millions of people, I understand that no guarantee of cure or improvement in my condition is given or implied.


9- Policies & Procedures

We may use or disclose your health information to provide you with appointment reminders and follow up communication via phone, voicemail, email or letter.


I have reviewed Sage Acupuncture LLC’s notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.

  • Payment is due at the time of service. We accept cash, checks, HSA, FSA, and most major credit cards.
  • Your appointment time is reserved specifically for you. In the event of a missed appointment or an appointment cancelled with less than 24 business hours notice you will be charged a fee.
  • We reserve the right to change our fee scale without notice.



10- Finish and Submit

I have completed this form to the best of my knowledge. I have read and understand the informed consent, privacy, and procedures information. By entering my initials below I agree to a course of treatment in Oriental Medicine and intend this consent form to cover the entire course of treatment for my present condition as well as any future condition(s) for which I seek treatment with this practice.

_______________________________________________________________________

Patient’s Name

Patient's Initials

Date