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This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you.
______________________ ____Acupuncture _____________________ _____
Previous Acupuncture? Yes No When? ____/____/_______ With Whom? ________________ Please indicate the use and frequency of the following:

Yes No Amount
Yes No Amount Yes No Amount
Tobacco "  _______ Water   ________ Alcohol   _______ Soda   ________ Please Check the Box if any of the following statements are true:
I have known allergies: Yes No I am taking Coumadin/ Warfarin/ Plavix: Yes NoI have a pace-maker: Yes No I am taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs) Yes NoI have a history of fainting or seizures Yes No Physician History
Have you seen a physician in the last year?  Yes  No If yes:Physician’s Name: _________________________________ Phone: ________________________Approximate date of most recent examination/visit? _____________________________________ What is your Chief health Complaint?
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Do you have any additional health concerns?
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Medications:
Please list any prescription or OTC medications or supplements and herbs you are currently taking:
Rx/Supplement/Herbs
Reason for
Prescribed by?
Date of last
taking the item? long?
check up?
List any allergies, food sensitivities you have.
_______________________________________________________________________________________
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List any accidents, surgeries or Hospitalizations (include date). _______________________________________________________________________________________
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How do you FEEL about the following areas of your life?
Please check the appropriate boxes and indicate any problems you may be experiencing.
______________________________________For Women______________________________________
# of Pregnancies ________ Age of Last Period (menopause) ________ # of live births ______ # of Abortions ______ # of Miscarriages ______ Number of days between Periods _______ Date of last: Gynecologic exam ____________ Pap smear _________ Number of days of flow ______________ Mammogram ______________Bone Density Scan ______________ Color of flow _______________________ Results _____________________________________________________Clots? Yes  No Color _______________________________________________________Average number of pads you use per day: 1st day ____ 2nd Day ____ 3rd Day ____ 4th day ____ +days _________ First Day of Last Period: ____________Have you been diagnosed with: Fibroids Fibrocystic Breasts Endometriosis Ovarian Cysts PID Other ________________Location of Pain: Lower Abdomen" (Please indicate before, during or after Menses) Bearing down sensation ______________________"
________________________________________For Men____________________________________
Date of last prostate check up __________ PSA results ____________ Manual prostate exam results ___________Lab results __________________________________________________________________________Frequency of Urination: daytime ________ nighttime ________ Color of urine: clear murky Symptoms related to prostate:Prostate problems Other __________________________________ __________________________Symptom Survey (for Everyone)________________________________
The following is a list of symptoms that you may or may not ever experience.
Please indicate as follows:
Leave Blank = never experience
check mark()= sometimes plus sign (+) = frequently experience pain or coldness in the light colored stool ------------------------------- soft brittle nails feeling the retention of food shortness of breath tendency to become obsessive decreased sense of smell spasms or twitching of -------------------------------
insomnia, difficulty sleeping skin problems feeling of claustrophobiaknee problems recent use of antibiotics hair loss

Source: http://wellnessconnectionllc.com/downloads/acupuncture_questionnaire.pdf