Medical History

This Information is essential for the diagnosis procedure and helps us to provide you with a better treatment. Please fill out as accurately as you can.

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THIS INFORMATION IS CONFIDENTIAL

Your Name (required)

Your Email (required)

Your Social Security Number

Your Health insurer:

Your Health insurer Relationship number:

Your Care pack:

Your phone number(s)

Your address/residence

Name/Adres/Residence of your family doctor

Birth date: Height: Weight:

What is your principle complaint?

What has been diagnosed (By M,D.)?

Any problems during your birth?

Vaccination history. Any reactions that you remember?

Any unusual vaccinations?

Childhood Illnesses? Any surgery or accidents?

Age:

Age:

Age:

What kind of adolescence Illnesses did you have? Are there any surgery or accidents?

Age:

Age:

Age:

What about adulthood illnesses? Are there any surgery and/or accidents?

Age:

Age:

Age:

Age:

Age:

Please note all major illnesses in your immediate family, like diabetes, heart disease, blood pressure, neurological disorders, psychological disorders, blood disorders, orthopedic disorders etc.

Are you taking any medication? Please note all medication, herbs, vitamins, and minerals you take even if you take them only occasionally.

Do you have any scars? Note location of all operation or injury scars (even minor ones).

SYMPTOM LIST

Check any problem, disease, or symptom you have now. Mark items that affected you in the past.

Skin:

eczemaacneskin rashesdermatitisfurunclesfungal infectionswartspsoriasis

Heart and vascular:

fast pulse (over 100 beats/min.)slow pulse (less than 60 beats/min)palpitationirregular pulsefeeling of pressure in the chestshort of breathchest paindizzinessmigraineheadache with nauseacold hands/feetRaynaud's diseaseflushed faceanemiahigh blood pressurelow blood pressurecold sweatsred facefeel dizzy or faint when standing up quickly or standing for a long time

Gastrointestinal:

constipationdiarrheano appetitestomach painindigestionheartburnintestinal gasbelchingulcergastritislack of stomach acidhemorrhoidsileocecal valvespasmperitonitispancreatitisirritable bowelpolypsGI stromal tumors

Respiratory:

asthmabronchitisemphysemacoughwheezepneumonialung abscesspneumothorax (collapsed lung)

Hormonal imbalance:

low thyroidoveractive thyroiddiabeteshypoglycemiablood sugar

Other hormone imbalance:

Male:

impotencepremature ejaculationprostate gland problemvasectomy (sterilization)infertility

Female:

menstrual problemscramping heavy/light/irregular periodsPMS (Premenstrual syndrome)emotional reactionsmenopause symptomstubal ligationinfertilitylow libido

Autoimmune and inflammatory conditions:

Hashimoto's disease (thyroid)rheumatismsystemic lupuserythematosus colitisCrohn's diseasealopecia (baldness)allergy foodallergy atopicdermatitisneurodermatitiscellulitis (skin infection)sinus allergyvulvitislow immunity

Effects of focal infections:

rheumatic diseaserheumatic feverarthritisskin disease

Connective tissue or ligament diseases:

Myofascial pain syndromefibromyalgiatendinitisligaments pericarditisconstant slight feverglomerulonephritisplantar fasciitisscarlet feverear infectionsstreptococci infectionsstaphylococci infectionseasily catch cold or sore throatswollen glands

Ear, nose & throat:

deafnesstinnitus (ringing in the ear)itchy earear painfrequent ear infectionssinus head achesyellow mucusstuffy nosepost-nasal dripdry throatitchy throatconstant sinus congestionstreptococcithroat infectionssore throat

Oral diseases:

bleeding gumsperiodontitisdental abscess mumpsstomatitis (inflammation of the mouth)TMJ (temporomandibular joint dysfunction)toothaches without cavities

General:

insomniapsychosomatic weaknessexhaustionemotional problems (angry, irritable, depressed, anxious)difficult concentrating on a taskeasily get car sick, sea sick, or air sickno appetite for breakfastmoody in morningsunusual sweating (palm, sole, or elsewhere)never sweat

Before noon time:

no energyfeel spacey, scattered mindedenergetic all evening through midnight, but hate to wake up early in the morninglong shower or bath makes you feel dizzy or faint

Medication and drugs:

birth control pillcigarettesalcoholcocainemarijuana

Please drop here your complete life story as detailed as possible. Especially the ones according to you that are responsible for your complaint:

State here as honestly and as detailed possible what your expectations are of the session:

For cosmetic acupuncture please specify oversensitivity or allergy for cremes and other fluids:

Attachment(s) (for cosmetic acupuncture please provide detailed photos of your face)

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