New Patients

Health history questionnaire

Please fill out the following information as completely as possible. If a section or question does not pertain to your health concern please leave it blank.

1- Personal Information

Have you been treated by acupuncture before? YN

I have been evaluated by a physician for the condition(s) being treated within the past 12 months:YN

May we share information with your other healthcare providers? YN

2- General Health History

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


Muscle twitching / spasm

Neck / shoulder tension

Brittle nails

Genital itching / pain / rashes

Discharge from nipples

Irritability / frustration / impatience



Emotional eating

Unfulfilled desires


Feeling of lump in throat

Sensation or pain under rib cage



Chest pain / tightness

Insomnia / Sleep problems


Aversion to heat

Bitter taste in mouth

Tongue / mouth ulcers / cankers

Restless / easily agitated


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