CONFIDENTIAL HEALTH HISTORY QUESTIONNAIRE
COMPASSIONATE ACUPUNCTURE AND HEALING ARTS
Barbara Connor, M.Ac., L.Ac. and John G. Connor, M.Ac., L.Ac.
4501 Valley Forge Road, Durham, NC27705
(919) 309-7753
Date:_________________________
Name:________________________ Phone: (Home)____________________________
Phone (Work)__________________ Phone: (Cell)______________________________
Address:___________________________________ City:_______________________
State_______ Zip_______ E-mail:__________________________________________
Age:_______ Date of birth_____________ Height________ Weight________
Blood pressure: _____ Marital status :___ Occupation.:_____________________________
Employer's name:__________________________________________________________
Current health care practitioners: _______________________________________________
________________________________________________________________________
Referred by: ______________________________________________________________
In emergency notify: ____________________ Phone: _____________________________
Main problem(s) you would like me to help you with: _______________________________
________________________________________________________________________
Please check if you have had or have at present any of the following:
Allergies ____ Asthma _____ Arteriosclerosis _____ Arthritis____ Artificial Joints _____ Cancer______
Chemotherapy ___ Chronic Cough _____ Chronic Diarrhea _____
Diabetes_____ Hepatitis _____ HIV/AIDS_____
Kidney Stones____ Liver Disease___ Lyme Disease____
Pacemaker ___ Seizures /Epilepsy___ Stroke____
Thyroid Disease___ Ulcer _____ Venereal Disease ____
Have you been treated by acupuncture or Oriental medicine before? ____________
Illnesses & surgeries (include treatments an hospitalizations): ______________________ ____________________________________________________________________
Trauma (car accidents, falls, etc.): __________________________________________
____________________________________________________________________
Birth history (prolonged labor, forceps delivery, etc): _________________________
Family medical history (check): Allergies __ Asthma__ Cancer___ Diabetes____
Heart Disease___ High Blood Pressure__ Seizures __ Stroke _____ Other____________
Medicines you have taken within the last twelve months (vitamins, drugs, herbs, etc.): ________________________________________________________________________
Medications or herbs you have allergies to: _______________________________________
Occupational stress (chemical, physical, psychological, etc.): __________________________ ________________________________________________________________________
Do you have a regular exercise program? Yes ____ No ____ What kind? ____________ _______________________________________________________________________
Have you been or are you on a restricted diet? Yes____ No ___ What kind? __________ ________________________________________________________________________
Please describe your average daily diet:
Breakfast: __________________________________________________________
Lunch: __________________________________________________________
Dinner: __________________________________________________________
How many cigarettes do you smoke per day? ________
How much coffee, tea or cola do you drink per day? ____
How much alcohol do you drink per week? ____
Please describe any use of drugs for non-medical or recreational purposes: ________________________________________________________________________
PLEASE CHECK ANY YOU HAVE HAD IN THE LAST YEAR
__ Chills __ Fevers __ Sweat easily
__ Night sweats __ Localized weakness __ Bleed or bruise easily
__ Peculiar taste or smells __ Strong thirst (cold or hot) __ Thirst, no desire to drink
__ Fatigue __ Sudden drop in energy. Time of day? _______
__ Edema __ Poor sleep __ Tremors
__ Cravings __ Change in appetite __ Weight gain
__ Weight loss Other_______________________________________
SKIN AND HAIR:
_ Rashes __ Itching __ Change in hair or skin
__ Ulcerations __ Eczema __ Oozing from skin lesion
__ Hives __ Pimples __ Recent moles
__ Loss of hair __ Dry skin Other: ____________
HEAD, EYES, EARS, NOSE AND THROAT:
__ Dizziness __ Facial pain __ Migraines
__ Headaches When? ______________ Where? _________________
__ Poor vision __ Blurry vision __ Color blindness
__ Blind field __ Spots in front of eyes __ Eye pain
__ Eye strain __ Cataracts __ Eye dryness
__ Excessive tears __ Discharge from eyes __ Poor hearing
__ Ringing in ears __ Earaches __ Discharge from ear
__ Nose bleeds __ Sinus congestion __ Teeth grinding
__ Teeth problems __ Concussion(s) __ Recurrent sore throats
__ Hoarseness __ Sores on lips or tongue Other: ______________
CARDIOVASCULAR:
__ High blood pressure __ Low blood pressure __ Chest discomfort/pain
__ Heart palpitations __ Cold hands or feet __ Swelling of hands
__ Swelling of feet __ Blood clots __ Fainting
__ Difficulty breathing Other cardiovascular problems: ___________________
RESPIRATORY:
__ Cough __ Asthma/wheezing __ Pain with a deep breath
__ Difficulty in breathing when lying down __ Coughing blood
__ Production of phlegm What color? ___________ __ Bronchitis
__ Pneumonia Other lung problems: ____________________________
GASTROINTESTINAL:
__ Nausea __ Vomiting __ Heartburn
__ Belching __ Indigestion __ Diarrhea
__ Constipation __ Chronic laxative use __ Blood in the stools
__ Abdominal pain/cramps __ Gas __ Rectal pain
__ Hemorrhoids Other stomach or intestinal problems: _____________
UROGENITAL:
__ Pain on urination __ Urgency to urinate __ Frequent urination
__ Blood in the urine __ Decrease in flow __ Unable to hold urine
__ Dribbling urine __ Impotency __ Change of sexual desire
__ Sores on genitals __ Night-time urination How often? _______________
Color of urine: _______ Other urogenital problems: _______________________
GYNECOLOGY AND PREGNANCY:
Number of pregnancies __ Number of births __ Premature births __
Miscarriages __ Abortions __ Age at first menses ______
Days between menses __ Length of periods __ First date of last menses __
__ Unusual character (light or heavy) __ Painful periods
__ Irregular periods __ Changes in body/psyche prior to menstruation
__ Clots __ Menopause at age __ __ Vaginal discharge
__ Vaginal sores Last Pap ____________ __ Breast lumps
__ Practice birth control What type and for how long?_____________________
__ Nipple discharge Other: ____________________________________
NEUROPSYCHOLOGICAL:
__ Seizures __ Area of numbness: Where? __________________
__ Weakness __ Sleep disorder __ Poor memory
__ Bad temper __ Loss of control/violence potential
__ Depression __ Anxiety __ Easily susceptible to stress
__ Vertigo __ Loss of balance __ Lack of coordination
__ Muzzy headedness/lack of clarity __ Substance abuse
Have you every been treated for emotional problems? Yes __ No __
Have you ever considered or attempted suicide? Yes __ No __
Other neurological or psychological problems: _______________________________
MUSCULOSKELETAL:
__ Neck pain __ Shoulder pain __ Back pain
__ Elbow pain __ Hand/wrist pain __ Hip pain
__ Knee pain __ Foot/ankle pain __ Muscle pains
__ Muscle weakness __ Heaviness in the limbs
Other musculoskeletal problems: ____________________________________________
Please indicate painful or distressed areas:
Please note: You will be charged the full fee for missed appointments without 24 hours advance notice.