Acupuncture & Natural Therapies/ Melanie Myers

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