Return to Forms

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_____________ Occupation.:___________________________

Employer's name:__________________________________________________________

Full time:___ Part time: ___ School: ___ Retired: ___ Unemployed: ___ Other: ___

Support activities/pursuits/groups: _____________________________________________

Living Situation: Alone: ___ Friends: ___ Spouse: ___ Partner: ___ Parents: ___ Children: ___

Name of Partner/Spouse: ___________________________________________________

In emergency notify: ____________________ Phone: _____________________________

Referred by: _____________________________________________________________

Main health issues you would like to address at this time : ____________________________

________________________________________________________________________

CANCER INFORMATION

Have you ever been diagnosed with cancer, a mass or a tumor? Yes: ___ No: ___ When: ____

Location: __________________________ Type: _________________________________

Current status (eg. post surgery, recurrence, etc.): __________________________________

Current Stage: _______________ Relevant Tumor Markers: _________________________

CONVENTIONAL TREATMENT HISTORY

Date Surgery/Chemotherapy/Radiation/Other Dose (eg. chemo agents) Duration

___________________________________________________________________________________

If you are in a clinical trial or experimental protocol please provide details: __________________

CURRENT/RECENT HEALTH CARE PROVIDERS (Surgery, Oncology, Primary Care Providers)

Name Dates Care Provided

___________________________________________________________________________________

FAMILY HISTORY

Please include any of the following: Alcoholism, high blood pressure, cancer, diabetes, heart disease, osteoporosis, other addiction or illness.

Member Living? Age Important Diseases Causes of death Age

Mother____________________________________________________________________________

Father_____________________________________________________________________________

Siblings____________________________________________________________________________

Maternal Grandmother________________________________________________________________

Maternal Grandfather ________________________________________________________________

Paternal Grandmother________________________________________________________________

Paternal Grandfather_________________________________________________________________

Please check if you have had or have at present any of the following:

Allergies ____ Asthma _____ Arteriosclerosis_____ Arthritis____ Artificial Joints _____ Crohn's______

Chronic Cough _____ Chronic Diarrhea _____ Colitis ______ Diabetes_____ Diverticulitis _____ Hepatitis _____ HIV/AIDS_____ Kidney Stones____ Liver Disease___

Lyme Disease____ Mononucleosis ____ Pacemaker ___

Parasites _______ Seizures /Epilepsy___ Stroke____

Thyroid Disease___ Ulcer _____ Venereal Disease ____

Have you been treated by acupuncture or Oriental medicine before? ____________

HOSPITALIZATIONS / SURGERY (NON CANCER)

Date Hospital Diagnosis/Operation Doctor

___________________________________________________________________

ACCIDENTS / INJURIES Briefly Descrbe:

More than 5 years ago _________________________________________________

Less than 5 years ago__________________________________________________

Height______Weight______Blood pressure: _____ Skin: Dry ___ Oily ___Normal___

Birth history (prolonged labor, forceps delivery, etc): _________________________

Please rate the following on a scale of 1 to 10 (10 being the best) - write any comments

Sleep___________________________ Energy Level ____________________________

Appetite _________________________ Digestion ______________________________

Do you rely on any of the following for bowel elimination? (Yes or No) Enemas _____

Laxatives _____ Purgatives _____ What type or brand? ________________________

Name of Current Supplements or Herbs Dosage Frequency___ _______________________________________________________________________

_______________________________________________________________________

Name of Medication What it is for? Dosage Frequency___

_______________________________________________________________________

Medications or herbs you have allergies to: _______________________________________

Occupational stress (chemical, physical, psychological, etc.): __________________________ ________________________________________________________________________

Have you ever been exposed to pesticides, toxic chemicals, heavy metals, radiation, or other

toxins beyond those encountered in daily life? _____________________________________

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? (Specify) __________________

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

GENERAL

__ 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 - At what time of day? ______

__ Edema __ Poor sleep __ Tremors

__ Cravings __ Change in appetite __ Weight gain

__ Weight loss Other_______________________________________

SKIN & 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._________________________________

How would you rate your pain levels on a scale of 0 - 10 ( 10 being worst pain level)

Please note: You will be charged the full fee for missed appointments without 24 hours advance notice.