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Fredericksburg Acupunture Specialist

Medical History 1
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Medical History Form

Name________________________________________________Date_____________________________

Male___ Female____ Age____ Married____ Divorced____ Single____ Date of birth:_________________

occupation__________________________________ Referred by:_________________________________

Mailing Address:________________________________________________________________________

Email Address:_________________________ Emergency Contact and #:___________________________

Home Phone:_______________Cell Phone/other:_________________Physician:_____________________

Chief Complaint:_______________________________________________________________________

Date of Onset___________________

Current Medications: _____________________________________________________________________________________

Other Concurrent Therapies & Dr.Name & #________________________________________________

_____________________________________________________________________________________

Allergies(drugs, chemicals, food)___________________________________________________________



NOW:( )Pregnant ( )Pacemaker ( )Aids ( )Hepatitis ( )Blood Transfusions ( )Implants/Artificial parts



Past Medical History/Illnesses: (include date)

__Arthritis __Asthma __Auto Immune Disease __Alcoholism __Bronchitis __Cancer

__Chronic Fatigue Syndrome __Chronic Lung Disease __Diabetes/Hypoglycemia __Drugs __Heart Disease __Hepatitis __Hernia __High Blood Pressure __Kidney Disease

__Organ Transplant __Pneumonia __Rheumatic Fever __Seizures/Epilepsy

__Sexually Transmitted Diseases(STD) __Thyroid Disease __Tuberculosis

__Ulcers __Vaccine Reaction __Whooping Cough



Surgeries:_____________________________________________________________________________

Significant Trauma(auto Accidents, falls, etc)________________________________________________

Occupational Stresses(chemical, physical, Psychological, etc)



exercise:

Habits: __Cigarettes __Coffee __tea __Cola __Alcohol __drugs __sugar __Salt __Other___________



Family medical history: __Diabetes __cancer __High blood pressure __Heart disease __Stroke __Seizures __Asthma __Allergies __Alcoholism __Other_______________



GENERAL (Check all that apply now!)

__Poor appetite __Heavy appetite __Poor sleep __Heavy sleep

__Insomnia __Fatigue __Tremors __Vertigo

__cold hands __cold feet __cold back __cold abdomen

__Fevers __chills __night sweats __sweat easily

__cravings __localized weakness __poor coordination __ change in appetite

__sudden energy drop at_____a.m._____p.m. __peculiar tastes/smells______________________

__Strong thirst(cold/hot drinks)________________ __bleed or bruise easily(where)_________________



SKIN

__Rashes __Ulcerations __Hives __Itching

__Eczema __Pimples __ dandruff __Loss of hair

__Change in hair/skin texture __ purpura __other hair or skin

Other Problems with skin :

(whether it appears related or not to your reason for visit)



HEAD, EYES, EARS, NOSE, AND THROAT

__Dizziness __Concussions __ Migraines __Glasses

__Eye strain __Eye pain __Poor vision __Night blindness

__Color blindness __Cataracts __Blurry vision __Earaches

__Ringing in ears __Poor hearing __Nose bleeds __Sinus problems

__Mucus __Dry throat __Dry mouth __Copius saliva

__Teeth problems __Jaw clicks __Grinding teeth __Facial pain

__Gum problems __Spots in eyes __Recurrent sore Throats__________/Month

__Sores on lips or tongue __Headaches(where and when)_________________

__Other head or neck problems________________________________________________________________________________________

CARDIOVASCULAR

__High blood pressure __Low blood pressure __Chest pain __ Irregular heartbeat

__Dizziness __ Fainting __Cold hand/feet __Swelling in hands/feet

__Blood clots __Phlebitis __Difficulty breathing __other________________



GASTROINTESTINAL

__Gas __ Belching __Bad breath __Intestinal Pain or cramps

__Sensitive Abdomen __Rectal pain __Bloody stools __ Black stool

__Bowel movement: __________Frequency _____________Color ____________Odor __________Texture/form

__Diarrhea __Constipation __Hemorrhoids

__Laxative use:____/week;type_____________



RESPIRATORY

__Cough __Coughing blood __Breathing difficult __Wheezing

__Sneezing __Chest/ribs hurt __Coughing/Mucus



GENITO-URINARY

__Pain on urination __Frequent urination __Blood in urine __Urgency to urinate

__Unable to hold urine __Kidney stones __Venereal disease __Impotency

__Wake up to urinate; how often___________/night; time:_______________________



PREGNACY AND GYNOCOLOGY

Number pregnancies_________ Number births________ Premature births ________ Miscarriages________

Age at first menses__________ Period(cycle days)________ Duration________/mo. __ Irregular periods

each month do your periods; __start early __Start on time __start late

Flow(describe)______________________________ __Clotting Last PAP_________ Last menses________________

Vaginal Discharge, color________ __Vaginal sores __Breast lumps __Menopause

Birth control Type & duration ____________________________________________________________________



MUSCULOSKELETAL

__Neck pain __Muscle pain __Back pain __Joint pain(where)___________________

__Other joint or bone problems______________________________________________________________________

______________________________________________________________________________________________

NEUROPSYCHOLOGICAL

__Seizures __Areas of numbness __Poor memory __Concussion

__Depression __Anxiety __Bad temper __Easily stressed

__Treated for emotional problems __Considered or attempted suicide

Other neurological or psychological problems? ________________________________________________________



Do Not Write below this line/ For Acupuncturist’s findings

Yin/Yang:_______________________________________________________________________________________

Excess/Deficiency:_______________________________________________________________________________

Hot/Cold:_______________________________________________________________________________________

Surface/Interior:__________________________________________________________________________________

Suicidal now? __Patient denies



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©2007 Melanie Myers, All rights reserved