Missionvalleyacu.com

ORIENTAL MEDICAL HISTORY
Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All of your answers will be held absolutely confidential. If you have any questions, please ask. NAME_______________________________EMAIL________________Date_________ HOME PHONE_______________ CELL_______________WORK_________________ ADDRESS_______________________________City________State____Zip_________ DATE OF BIRTH_____________AGE_______ HEIGHT_________WEIGHT_________ MARITAL STATUS_________# OF CHILDREN & AGES_________________________ OCCUPATION______________________________________SSN_________________ EMPLOYER_____________________________________________________________ INSURANCE CO.___________________________________________________________________ MEMBER ID___________________________PHONE #_________________________ NAME POLICY IS UNDER________________________GROUP # ________________ WHOM MAY WE THANK FOR REFERRING YOU?_____________________________ HAVE YOU EVER HAD ACUPUNCTURE OR ORIENTAL MEDICINE TREATMENT BEFORE?_________ IN CASE OF EMERGENCY CONTACT_______________________________________ ADDRESS_____________________________________PHONE___________________ CHIEF COMPLAINT (please describe in your own words what you experience)
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Diagnosis by an MD? What?__________________________________________________________
When did this problem begin?_________________________________________________________
Characteristics?_________________________________How often?__________________________
What makes it feel better?______________________Worse?________________________________
What other forms of treatment have you sought?___________________________________________
List any other health problems you now have______________________________________________
List any allergies, food sensitivities or food cravings you have
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Have you had your tonsils removed?_________Appendix?_________Gall Bladder?_________ Have you had oral surgery?_____Please list___________________________________________________ Have you ever taken antibiotics for more than 10 days?_____When and for what?_____________________ Do you have a pacemaker?_____Taking Coumadin/Warfarin?______ Lithium (Eskalith, Lithobid, Lithonate, Lithotabs?_________ Have you ever had chemotherapy?_______When?______Radiation Therapy?___ _When?_____________ Are you current under the care of a physician or a therapist?_________________ What are you being treated for?____________________________________________________________ Have you recently had any unusually stressful experiences (i.e. divorce, death of someone close, bankruptcy, loss of job, illness, injury, etc)? Please list:____________________________________________________ What type of exercise do you get and how often?_______________________________________________ Please describe your average daily diet:

Morning_______________________________________________________________________________
Afternoon______________________________________________________________________________
Evening________________________________________________________________________________
Snacks_________________________________________________________________________________
Please list any dietary restrictions____________________________________________________________
How much of the following do you drink per day? Coffee (cups)_______ Tea (cups) _______
Water (oz)_____Soft Drinks (cans)_____Wine (glass)_____Beer (oz)_____Liquor (oz)_____
Hospitalizations/Surgeries (Please include dates):________________________________________________
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Please list all current medications. You may use the back of this sheet:
Medicine
How long?
________________________________________________________________________________________ Have you ever been alcohol or drug dependent? When?___________________________________ How much tobacco do you use per day?____________Marijuana?___________Other____________ Family Medical History Please check the diseases which other members of your family had:
__Cancer_________Who?
Disease________Who? __Asthma___________Who? __Alcoholism___________Who? __Stroke____________Who? __Hypertension_________Who? ________________Other
Which of the following diseases have you had?
SYMPTOM SURVEY
The following is a list of symptoms that you may or may not experience. Please indicate as follows:
leave blank if never experience check mark (a) if sometimes experience plus sign (+) if always experience
__difficulty digesting oily foods __nightmares __laughing for no apparent __increased sex drive __feeling retention of food in __dry eyes __difficulty in making plans or __prefer hot drinks __spasms or twitching of __thyroid disorders __intolerance to weather __irritability or easily angered MUSCULOSKELETAL
Pain or numbness in any of the following areas - if pain, please rate levels using a scale from 0-10, 0 is the
least and 10 is the worst.
___neck
Heat_____Cold_____Damp______Weather______Wind_____Medications_____Pressure____
What aggravates your pain/condition?
Heat_____Cold_____Damp______Weather______Wind_____Medications_____Pressure____
FOR WOMEN

Age of 1st period(menarche)_____________
Are you pregnant?______Trying?____________ Age of last period(menopause)___________ # of pregnancies______miscarriages_________ # of live births_____# of abortions____________ Date of last obgyn exam + results_____________ Avg # of pads per day 1st day____ 2nd day___ Bone Density Scan_______________________ 3rd day____4th day____5th day____+days___ __discharge____vaginal dryness_____headache ___nausea____constipation_____swollen breasts ___diarrhea___ravenous appetite___insomnia cramping__________stabbing_______________ ___hot flashes___poor appetite____libido burning___________aching_________________ dull______________bloating________________ consistent_________intermittent____________ Have you been diagnosed with (include year): _______fibroids_______endometriosis_______PID ________Ovarian cysts_______fibrocystic breasts FOR MEN
Date of last prostate exam__________PSA results__________Manual prostate exam results______________
Frequency of urination: daytime________nighttime________color of urine_________odor_______________
Symptoms related to prostate:
___prostate problems___delayed stream___dribbling___incontinence___retention of urine___impotence
___groin pain___testicular pain___premature ejaculation___back pain___5libido___6libido___rectal dysfunction Other___________________________________________________________________________________ ________________________________________________________________________________________

Source: http://www.missionvalleyacu.com/pdfs/newestintakeform.pdf