Medical History Form - Meridian Acupuncture & Wellness

HEALTH HISTORY

First Name:

Middle Initial:

Last Name:

Gender: Male Female

Date of Birth:

From whom are you currently receiving health care?

What, if any, contagious disease do you have at this time?

What childhood illnesses have you had?

What allergies to drugs or food do you have?

What current medications do you take and for what?

List vitamins/supplements you are currently taking.

YOUR MEDICAL HISTORY:

Chronic or continuing illnesses:

Surgeries, major illnesses, hospitalizations, and major accidents (include year):

History of Childhood Trauma? Yes No

Are you a former smoker? Yes No

How many packs per day?

Are you a current smoker? Yes No

How many packs per day?

What was your last blood pressure reading?

What is your normal body temperature reading?

FAMILY HISTORY:

Age (if living)

Father: Mother: Brother(s): Sister(s): Child(ren):

Health (G=good P=poor)

Father: Mother: Brother(s): Sister(s): Child(ren):

WHAT BRINGS YOU HERE TODAY?

What is the reason for your visit today?

How, when, and where did this condition begin?

What types of treatments have you tried, if any?

How does this condition impair your daily activities?

SYSTEMS REVIEW (Please select all that apply)

0=Never 1=rarely 2=occasionally 3=frequently 4=always

GROUP 1 Sympathetic Dominance

0 1 2 3 4

Acid foods upset

0 1 2 3 4

Get chilled often

0 1 2 3 4

"Lump" in throat

0 1 2 3 4

Dry mouth-eyes-nose

0 1 2 3 4

Pulse speeds after meal

0 1 2 3 4

Keyed up - fail to calm

0 1 2 3 4

Cut heals slowly

0 1 2 3 4

Gag easily

0 1 2 3 4

Unable to relax; startles easily

0 1 2 3 4

Extremities cold, clammy

0 1 2 3 4

Strong light irritates

0 1 2 3 4

Urine amount reduced

0 1 2 3 4

Heart pounds after retiring

0 1 2 3 4

"Nervous" stomach

0 1 2 3 4

Appetite reduced

0 1 2 3 4

Cold sweats often

0 1 2 3 4

Fever easily raised

0 1 2 3 4

Neuralgia-like pains

0 1 2 3 4

Staring, blinks little

0 1 2 3 4

Sour stomach often

GROUP 2 Parasympathetic Dominance

0 1 2 3 4

Joint stiffness on arising

0 1 2 3 4

Muscle-leg-toe cramps at night

0 1 2 3 4

"Butterfly" stomach, cramps

0 1 2 3 4

Eyes or nose watery

0 1 2 3 4

Eyes blink often

0 1 2 3 4

Eyelids swollen, puffy

0 1 2 3 4

Indigestion soon after meals

0 1 2 3 4

Always seems hungry; feels "lightheaded" often

0 1 2 3 4

Digestion rapid

0 1 2 3 4

Vomiting frequent

0 1 2 3 4

Hoarseness frequent

0 1 2 3 4

Breathing irregular

0 1 2 3 4

Pulse slow; feels "irregular"

0 1 2 3 4

Gagging reflex slow

0 1 2 3 4

Difficulty swallowing

0 1 2 3 4

Constipation, diarrhea alternating

0 1 2 3 4

"Slow starter"

0 1 2 3 4

Get "chilled" infrequently

0 1 2 3 4

Perspire easily

0 1 2 3 4

Circulation poor, sensitive to cold

0 1 2 3 4

Subject to colds, asthma, bronchitis

GROUP 3 Sugar Handling

0 1 2 3 4

Eat when nervous

0 1 2 3 4

Excessive appetite

0 1 2 3 4

Hungry between meals

0 1 2 3 4

Irritable before meals

0 1 2 3 4

Get "shaky" if hungry

0 1 2 3 4

Fatigue, eating relieves

0 1 2 3 4

"Lightheaded" if meals delayed

0 1 2 3 4

Heart palpitates if meals missed or delayed

0 1 2 3 4

Afternoon headaches

0 1 2 3 4

Overeating sweets upsets

0 1 2 3 4

Awaken after few hours sleep - hard to get back to sleep

0 1 2 3 4

Crave candy or coffee in afternoons

0 1 2 3 4

Moods of depression - "blues" or melancholy

0 1 2 3 4

Abnormal craving for sweets or snacks

GROUP 4 Cardiovascular

0 1 2 3 4

Hands and feet go to sleep easily, numbness

0 1 2 3 4

Sigh frequently, "air hunger"

0 1 2 3 4

Aware of "breathing heavily"

0 1 2 3 4

High altitude discomfort

0 1 2 3 4

Opens windows in closed rooms

0 1 2 3 4

Susceptible to colds and fevers

0 1 2 3 4

Afternoon "yawner"

0 1 2 3 4

Get "drowsy" often

0 1 2 3 4

Swollen ankles, worse at night

0 1 2 3 4

Muscle cramps, worse during exercise; get "charley horses"

0 1 2 3 4

Shortness of breath on exertion

0 1 2 3 4

Dull pain in chest or radiating into left arm, worse on exertion

0 1 2 3 4

Bruise easily, "black and blue" spots

0 1 2 3 4

Tendency to anemia

0 1 2 3 4

"Nose bleeds" frequent

0 1 2 3 4

Noises in head, or "ringing in ears"

0 1 2 3 4

Tension under the breastbone, or feeling of "tightness", worse on exertion

GROUP 5 Billiary and Liver

0 1 2 3 4

Dizziness

0 1 2 3 4

Dry skin

0 1 2 3 4

Burning feet

0 1 2 3 4

Blurred vision

0 1 2 3 4

Itching skin and feet

0 1 2 3 4

Excessive falling hair

0 1 2 3 4

Frequent skin rashes

0 1 2 3 4

Bitter, metallic taste in mouth in mornings

0 1 2 3 4

Bowel movements painful or difficult

0 1 2 3 4

Worrier, feels insecure

0 1 2 3 4

Feeling queasy; headache over eyes

0 1 2 3 4

Greasy foods upset

0 1 2 3 4

Stools light colored

0 1 2 3 4

Skin peels on foot soles

0 1 2 3 4

Pain between shoulder blades

0 1 2 3 4

Use laxatives

0 1 2 3 4

Stools alternate from soft to watery

0 1 2 3 4

History of gallbladder attacks or gallstones

0 1 2 3 4

Sneezing attacks

0 1 2 3 4

Dreaming, nightmare type bad dreams

0 1 2 3 4

Bad breath (halitosis)

0 1 2 3 4

Milk products cause distress

0 1 2 3 4

Sensitive to hot weather

0 1 2 3 4

Burning or itching anus

0 1 2 3 4

Crave sweets

GROUP 6 Digestive

0 1 2 3 4

Loss of taste for meat

0 1 2 3 4

Lower bowel gas several hours after eating

0 1 2 3 4

Burning stomach sensations, eating relieves

0 1 2 3 4

Coated tongue

0 1 2 3 4

Pass large amounts of foul-smelling gas

0 1 2 3 4

Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs .

0 1 2 3 4

Mucous colitis or "irritable bowel"

0 1 2 3 4

Gas shortly after eating

0 1 2 3 4

Stomach "bloating" after eating

GROUP 7A Hyperthyroid

0 1 2 3 4

Insomnia

0 1 2 3 4

Nervousness

0 1 2 3 4

Can't gain weight

0 1 2 3 4

Intolerance to heat

0 1 2 3 4

Highly emotional

0 1 2 3 4

Flush easily

0 1 2 3 4

Night sweats

0 1 2 3 4

Thin, moist skin

0 1 2 3 4

Inward trembling

0 1 2 3 4

Heart palpitates

0 1 2 3 4

Increased appetite without weight gain

0 1 2 3 4

Pulse fast at rest

0 1 2 3 4

Eyelids and face twitch

0 1 2 3 4

Irritable and restless

0 1 2 3 4

Can't work under pressure

GROUP 7B Hypothyroid

0 1 2 3 4

Increase in weight

0 1 2 3 4

Decrease in appetite

0 1 2 3 4

Fatigue easily

0 1 2 3 4

Ringing in ears

0 1 2 3 4

Sleepy during day

0 1 2 3 4

Sensitive to cold

0 1 2 3 4

Dry or scaly skin

0 1 2 3 4

Constipation

0 1 2 3 4

Mental sluggishness

0 1 2 3 4

Hair coarse, falls out

0 1 2 3 4

Headaches upon arising, wear off during day

0 1 2 3 4

Slow pulse, below 65

0 1 2 3 4

Frequency of urination

0 1 2 3 4

Impaired hearing

0 1 2 3 4

Reduced initiative

GROUP7C Hyperpituitary

0 1 2 3 4

Failing memory

0 1 2 3 4

Low blood pressure

0 1 2 3 4

Increased sex drive

0 1 2 3 4

Headaches, "splitting or rending" type

0 1 2 3 4

Decreased sugar tolerance

GROUP7D Hypopituitary

0 1 2 3 4

Abnormal thirst

0 1 2 3 4

Bloating of abdomen

0 1 2 3 4

Weight gain around hips or waist

0 1 2 3 4

Sex drive reduced or lacking

0 1 2 3 4

Tendency to ulcers, colitis

0 1 2 3 4

Increased sugar tolerance

0 1 2 3 4

Women: menstrual disorders

0 1 2 3 4

Young girls: lack of menstrual function

GROUP 7E Hyperadrenal

0 1 2 3 4

Dizziness

0 1 2 3 4

Headaches

0 1 2 3 4

Hot flashes

0 1 2 3 4

Increased blood pressure

0 1 2 3 4

Hair growth on face or body (female)

0 1 2 3 4

Sugar in urine (not diabetes)

0 1 2 3 4

Masculine tendencies (female)

GROUP 7F Hypoadrenal

0 1 2 3 4

Weakness, dizziness

0 1 2 3 4

Chronic fatigue

0 1 2 3 4

Low blood pressure

0 1 2 3 4

Nails weak, ridged

0 1 2 3 4

Tendency to hives

0 1 2 3 4

Arthritic tendencies

0 1 2 3 4

Perspiration increase

0 1 2 3 4

Bowel disorders

0 1 2 3 4

Poor circulation

0 1 2 3 4

Swollen ankles

0 1 2 3 4

Crave salt

0 1 2 3 4

Brown spots or bronzing of skin

0 1 2 3 4

Allergies - tendency to asthma

0 1 2 3 4

Weakness after colds, influenza

0 1 2 3 4

Exhaustion - muscular and nervous

0 1 2 3 4

Respiratory disorders

GROUP 8 Complex Deficiencies

0 1 2 3 4

Muscle weakness

0 1 2 3 4

Lack of Stamina

0 1 2 3 4

Drowsiness after eating

0 1 2 3 4

Muscular soreness

0 1 2 3 4

Rapid heart beat

0 1 2 3 4

Hyper-irritable

0 1 2 3 4

Feeling of a band around your head

0 1 2 3 4

Melancholia (feeling of sadness)

0 1 2 3 4

Swelling of ankles

0 1 2 3 4

Diminished urination

0 1 2 3 4

Tendency to consume sweets or carbohydrates

0 1 2 3 4

Muscle spasms

0 1 2 3 4

Blurred vision

0 1 2 3 4

Loss of muscular control

0 1 2 3 4

Numbness

0 1 2 3 4

Night sweats

0 1 2 3 4

Rapid digestion

0 1 2 3 4

Sensitivity to noise

0 1 2 3 4

Redness of palms of hands and bottom of feet

0 1 2 3 4

Visible veins on chest and abdomen

0 1 2 3 4

Hemorrhoids

0 1 2 3 4

Apprehension (feeling that something bad will happen)

0 1 2 3 4

Nervousness causing loss of appetite

0 1 2 3 4

Nervousness with indigestion

0 1 2 3 4

Gastritis

0 1 2 3 4

Forgetfulness

0 1 2 3 4

Thinning hair

FEMALE ONLY

0 1 2 3 4

Very easily fatigued

0 1 2 3 4

Premenstrual tension

0 1 2 3 4

Painful menses

0 1 2 3 4

Depressed feelings before menstruation

0 1 2 3 4

Menstruation excessive and prolonged

0 1 2 3 4

Painful breasts

0 1 2 3 4

Menstruate too frequently

0 1 2 3 4

Vaginal discharge

0 1 2 3 4

Hysterectomy / ovaries removed

0 1 2 3 4

Menopause hot flashes

0 1 2 3 4

Menses scanty or missed

0 1 2 3 4

Acne, worse at menses

0 1 2 3 4

Depression of long standing

MALE ONLY

0 1 2 3 4

Prostate trouble

0 1 2 3 4

Urination difficult or dribbling

0 1 2 3 4

Night urination frequent

0 1 2 3 4

Depression

0 1 2 3 4

Pain on inside of legs or heels

0 1 2 3 4

Feeling of incomplete bowel evacuation

0 1 2 3 4

Lack of energy

0 1 2 3 4

Migrating aches and pains

0 1 2 3 4

Tire too easily

0 1 2 3 4

Avoids activity

0 1 2 3 4

Leg nervousness at night

0 1 2 3 4

Diminished sex drive

WOMEN ONLY:

At what age did you get your first period:

Date of last menstrual cycle:

Are you currently on birth control? Yes No

If yes, what kind?

Are you pregnant now? Yes No

Number of days from the start of one period to the start of the next:

Average number of days of flow:

Are your menstrual cycles spaced regularly? Yes No

Flow is: Light Normal Heavy

Color is: Light Red Red Dark Red Purple Brown

Do you have blood clots? Yes No

Does you period cause you pain or cramping? Yes No

If yes, when? Before During After period

Fibrocystic breasts? Yes No

Do you experience any of the following before your period each month?
Water retention Breast tenderness or swelling Mental depression Irritability Food cravings Migraines Other

Number of pregnancies:

Number of abortions:

Number of live births:

Number of miscarriages:

Are you in menopause? Yes No

When?

MEN ONLY:

Have you been diagnosed with prostate problems? Yes No

Have you been diagnosed with infertility? Yes No

Thank you for taking the time to fill out this form as completely as possible. Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient’s physical, mental and emotional state.

Patient's Name:

Date:

Your submission is being processed.

You can print out your form by following this unique link. Do not share it with anyone. https://meridianacupuncture.com/resources/forms/patient-form/print-form/?auth={{code}}

Thanks for your submission.

Please print this form out or save as PDF and bring it with you to your appointment in case the submission failed.

Secure HIPAA compliant forms by FireSpike LLC 1-800-996-9689