II

Kang Acupuncture & Herbal Medicine Center

13400 Northup Way, Suite 3, Bellevue, WA 98005 TEL: (425) 401-8885
Health History Questionnaire
Date: --I---.l__
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. If there is
anything you wish to bring to our attention that is not asked on this form, please note in the Comments Section
on page 4. Thank you.
Name I Social Security Number
Address
I City
I State I Zip Code
Home Phone
I Work Phone ICellular Phone
Sex Age
Date of Birth I Place of Birth I Marital Status
Height
I Weight
Employer Name
I Occupation
Family Physician
IPhone
Address
ICity
. ~ State IZip Code
Emergency Contact Name Emergency Contact Phone I Have you been treated by acupuncture or
oriental medicine?
Whom we should thank for -referred by:
What is/are the main problem(s) you would like us to help you with:
How long ago did this problem begin (be specific)?
To what extent does this problem interfere with your daily actiVities (work, sleep, sex)?
Have you been given a diagnosis for this problem? If so what?
What kinds of treatment have you tried?
Past Medical History:
Cancer _ High Blood Pressure _ Heart Disease _
Diabetes _ HIV/AIDS _
Seizures _
Hepatitis _ Rheumatic Fever _ Venereal Disease _
Other _
1
Surgeries (type of and date):
Significant Trauma (auto accidents, falls, etc.):
Significant Dental Work (type and date):
Birth- History (prolonged labor, forceps delivery, etc.):
Allergies (drugs, chemicals, foods/result):
Fam iIy Medical History (check): IJ Diabetes
10 Cancer
[J Other:
n High Blood Pressure
n Heart Disease
[J Stroke
o Seizures
f1 Asthma
11 Allergies
_
Medicines taken within the last two months (vitamins, drugs, herbs, etc.):
Occupational Stress (chemical, physical, psychological, etc.):
Do you have a regular exercise program? [] Yes.
Please describe:
0 No.
_
Have you ever been on a restricted diet?
What kind?
[J Yes. n 1\10.
_
Please Describe Your Average Daily Diet
Morning: _
Afternoon: _
Evening: __
How many packs of cigarettes do you smoke per day?
How much alcohol do you drink per week?
How much coffee, tea or cola do you drink per week?
Please describe any use of drugs for non-medical purposes:
_
_
Please Check Any Symptons You Have Had in the Last Three Months
General
I
0 Chills
0 Fevers
0 Sweat easily
0 Night sweats
0 Localized weakness
0 Bleed or bruise easily
0 Peculiar tastes or
smells
Q
Strong thirst (cold or
hot)
Q
Thirst, no desire to
drink
0 Fatigue
0 Sudden energy drop
0
0
0
CJ
0
0
0
CJ
0
CJ
0
Q
Time of day?
Edema
Where:
Poor sleeping
Tremors
Poor balance
Cravings
Change in appetite
Poor appetite
Weight gain
Weight loss
Skin and Hair
Rashes
Itching
Change in hair or skin
0 Ulcerations
0 Eczema
0 Oozing on skin lesion
0 Hives
0 Pimples
0 Recent moles
0 Loss of hair
0 Dandruff
Other hair or skin
problems:
Head, Eyes, Ears,
Nose And Throat
CJ Dizziness
Q
Migraines
0 Headaches
When:
Where:
0 Facial pain
0 Glasses
0 Poor vision
0 Night blindness
0 Blurry vision
0 Color blindness
Q
Blind field
0 Spots in front of eyes
0 Eye pain
0 Eye strain
0 Cataracts
0 Eye dryness
0 Excessive tear
Q
Discharge from eyes
0 Poor hearing
2
o Ringing in ears
o Earaches
o Discharge from ear
o Nose bleeds
o Sinus congestion
o Nasal drainage
o Grinding teeth
o Teeth problems
o Jaw clicks
o Concussions
o Recurrent sore throats
o Hoarseness
o Sores on lips or tongue
Other head or neck problems:
I
Cardiovascular
---------------'
o High blood pressure
o Low blood pressure
o Chest discomfort/pain
o Heart palpitations
o Cold hands or feet
o Swelling of hands
o Swelling of feet
o Blood clots
o Fainting
o Difficulty in breathing
Other heart or blood vessel
problems:
Respiratory
o Cough
o Asthma/wheezing
o Pain with a deep breath
o Difficulty in breathing when lying
down
o Production of phlegm. What
color: _
o Coughing blood
o Pneumonia
o Bronchitis
Other lung problems:
Gastrointestinal
o Bad breath
o Nausea
o Vomiting
o Heartburn
o Belching
o Indigestion
1:1 Diarrhea
o Constipation
o Chronic laxative use
o Blood in stools
o Black stools
o Abdominal pain or cramps
o Gas
o Rectal pain
o Hemorrhoids
Other stomach or intestinal
problems:
1__G_e_n_i_ta_I_-u_ri_n_a_ry __
0 Pain on urination
o Urgency to urinate
o Frequent urination
o Blood in urine
o Decrease in flow
o Unable to hold urine
o Dribbling
o Kidney stones
o Impotency
o Change of sexual drive
o Sores on genitals
Do you wake up to urinate?
I] Yes. 0 No.
How often?
Any particular color to you urine?
Other genital or urinary system
problems:
Pregnancy And
Gynecology
Number of pregnancies: ---'-_
Number of births: _
Number of premature births:
Number of
Number of abortions:
_
_
Age at first menses: _
Period between menses (days):
Duration of menses (days):
First date of last menses:
__----'I / _
a Heavy periods
a Light periods
(J Painful periods
3
o Irregular periods
(J Changes in body/psyche prior to
menstruation
(J Clots
(J Menopause:
Age Year
o Vaginal discharge
Do you practice birth control?
n Yes. [I No.
What type and for how long?
Musculoskeletal
o Neck pain
o Shoulder pain
o Back pain
o Elbow pain
o Hand/wrist pain
o Hip pain
o Knee pain
a Foot/ankle pain
(J Muscle pain
(J Muscle weakness
Neuropsychological
o Seizures
(J Areas of numbness
o Weakness
o Sleep disorder
a Concussion
(J Bad temper
a Loss of control/violence potential
o Vertigo
a Lack of coordination
a Depression
(J Easily susceptible to stress
a Loss of balance
a Poor memory
(J Anxiety
a Substance abuse
Have you ever been treated for
emotional problems?
IJ Yes. D No.
Have you ever considered or
attempted suicide?
DYes. 0 No.
Other neurological or psychological
problems:
Please note the degree of severity of your problem now:
1 2 3 4 5 6 7 8 9 10
No problem Worst Imaginable
Please note the greatest degree of severity of your problem within the last
week:
1
No problem
2 3 4 5 6 7 8 9 10
Worst Imaginable
Indicate painful or distressed areas:
Identify CURRENT symptomatic areas in your body by drawing the symbols on the figures below.
KEY: Circle areas of PAIN 0
X "X" over areas of JOINT AND MUSCLE STIFfNESS
H Draw a squiggly lines along the areas of NUMBNESS OR TINGLING
-Ht Mark SCARS, BRUISES or OPEN WOUNDS
J