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Whole Body Health Acupuncture Center

 

Heather Vandeburg L.Ac., MSOM

547 W State St Sycamore IL 60178

Ph (815) 751-6424     

 

Thank you for choosing our office!!  In order to serve you properly, we need the following information.   All information will be kept confidential.

 

Please Print

Patient Name:

 

Today’s Date:

 

 

Home address:

City:

 

 

State:

Zip:

Home phone:

Work Phone

Email address:

 

 

Birth date:

Social Security #:

Height :

Weight:

 

 

Circle appropriate:    

         Minor               Single               Married               Divorced               Separated               Widowed

 

Person to contact in case of emergency:

Their Relationship to you:

Their Phone Number:

 

 

Patient’s Occupation:

 

 

Who might we thank for referring you?

 

 

Insurance information:

Insurance company:

 

 

Referring Physician:

Patient’s (or parent/guardian’s) employer:

 

 

Business Address:

 

 

City:

State:

 

Zip:

Spouse (or parent/guardian’s) Name:

 

 

Spouse’s Occupation:

Spouse (or parent/guardian’s) Employer:

 

 

Spouse’s Work phone:

Office Notes:

 

 

 

 

 

 

 

 

 

 

HEALTH HISTORY QUESTIONNAIRE

 

Have You ever been treated with Acupuncture or Oriental Medicine before??     YES       NO

What Main Problem(s) would you like us to help you with?

 

 

 

 

What Other Medical treatment(s) or alternative therapies have you tried for this problem?

 

 

 

 

DO YOU CURRENTLY HAVE PROBLEMS WITH ANY OF THE FOLLOWING?

 

Allergies

 

High Blood Pressure

 

Recurrent Infections

 

Arthritis

 

High Cholesterol

 

Recurrent Sore Throats

 

Asthma

 

Kidney Disease

 

Sensitivities

 

Cancer

 

Kidney (or Bladder) Stones

 

Sinus Congestion

 

Chronic Infections

 

Liver Disease

 

Sprains or Bruising

 

Diabetes

 

Lung Disorder

 

Stomach Disorders

 

Eye Disease

 

Menopausal Symptoms

 

Substance abuse

 

Fatigue

 

Mental Illness

 

Tuberculosis Exposure

 

Food Cravings

 

Numbness or tingling

 

Tumor

 

Gall Bladder Disease

 

Obesity

 

Varicose Veins

 

Heart Disease

 

PMS

 

Wear Eyeglasses

 

Heart Burn

 

Poor Circulation

 

Other:

 

Headaches /  Migraines

 

Psoriasis, Eczema, Acne

 

Other:

 

Hemorrhoids

 

Recent Surgery

 

Other:

 

FAMILY HISTORY:

Relatives

 

                            If Living

                           If deceased

 

Age

Health (good, fair, poor)

Death age

Death cause

Father

 

 

 

 

Mother

 

 

 

 

Brothers/Sisters

(Circle sex)

 

 

 

 

1.      M        F

 

 

 

 

2.      M        F

 

 

 

 

3.      M        F

 

 

 

 

4.      M        F

 

 

 

 

5.      M        F

 

 

 

 

Spouse

 

 

 

 

 

Sons/ daughters

(Circle sex)

 

 

 

 

1.      M        F

 

 

 

 

2.      M        F

 

 

 

 

3.      M        F

 

 

 

 

4.      M        F

 

 

 

 

5.      M        F

 

 

 

 

6.      M        F

 

 

 

 

 

Please list any blood relatives who have or have had any of the following conditions:

 

Yes

No

Relationship

 

Yes

No

Relationship

Alcoholism

 

 

 

High Blood Pressure

 

 

 

Allergies

 

 

 

Kidney Disease

 

 

 

Anemia

 

 

 

Leukemia

 

 

 

Arthritis/ Rheumatism

 

 

 

Mental Illness

 

 

 

Asthma

 

 

 

Migraine/ Headache

 

 

 

Bleeding Tendency

 

 

 

Nervous Breakdown

 

 

 

Cancer

 

 

 

Obesity

 

 

 

Colitis

 

 

 

Rheumatic Fever

 

 

 

Congenital Heart

 

 

 

Stomach Ulcers

 

 

 

Diabetes

 

 

 

Stroke

 

 

 

Epilepsy

 

 

 

Suicide

 

 

 

Goiter

 

 

 

Tuberculosis

 

 

 

Heart Disease/ Stroke

 

 

 

Other:

 

 

 

 

Your Personal Habits:

Do you smoke?

 YES         NO

If Yes, # of packages per day

 

Do you Drink Coffee?

 YES         NO

If Yes, # of cups per day

 

Do you Drink alcohol?

 YES         NO

If yes, # of drinks per day

 

 

 

If available, please bring your most recent lab/blood work results to your first session.

Document your Test Levels of the following, if known:

Blood Pressure Level:

 

Cholesterol level:

 

 

Check any you are you currently taking or have taken within the last 3 months:

 

Antacids

 

Cough Medicine

 

Steroids

 

Antibiotics

 

Herbs

 

Tranquilizers

 

Aspirin

 

Insulin / Diabetic pills

 

Thyroid medication

 

Blood Pressure Pills

 

Iron Pills

 

Vitamins

 

Blood Thinning Pills

 

Laxatives

 

Water Pills

 

Birth Control Pills

 

Sleeping Pills

 

Weight Reducing Pills

 

 

BRIEF HEALTH HISTORY

Operations you have had:

 

 

Include Years

Diseases you had requiring hospitalization:

 

 

Include Years

Serious Illnesses you had not requiring hospitalization:

 

 

Include Years

Describe any serious injuries or accidents you have had:

 

 

Include Years

Have you ever worn a neck or back brace? 

YES        NO

List any known Drug Allergies you have:

 

 

 

 

 

PLEASE LIST YOUR MEDICATIONS:

NAME

DOSAGE

INDICATION

LENGTH OF TREATMENT

1.

 

 

 

2.

 

 

 

3.

 

 

 

4.

 

 

 

5.

 

 

 

6.

 

 

 

7.

 

 

 

8.

 

 

 

 

PLEASE LIST YOUR SUPPLEMENTS OR OVER THE COUNTER MEDICATIONS:

NAME

DOSAGE

INDICATION

LENGTH OF TREATMENT

1.

 

 

 

2.

 

 

 

3.

 

 

 

4.

 

 

 

5.

 

 

 

6.

 

 

 

7.

 

 

 

 

HEART

 

Normal Blood

Pressure

 

Low Blood

 Pressure

 

High Cholesterol

 

Palpitations

 

High Blood

Pressure

 

Dizziness upon

standing

 

Congenital Disease

 

 

Explain:

 

 

Professional Notes:

 

 

 

 

 

HEADACHES

Do you frequently have Headaches?     YES   NO   (If yes, answer the following):

 

Cause visual trouble?

 

Do they occur on the side?

 

What is the duration?

 

Awaken you at night?

 

                        On the back?

 

Does aspirin relieve them

 

Pain is  sharp and stabbing

 

                         In the front?

 

Do they involve dizziness or weakness

 

Pain is  dull and achy

 

                         At the eyes?

 

Pain feels  like a tight band?

 

                         On top?

 

Are they aggravated by

Overwork?

 

Head feels heavy?

 

                         Sinus area?

Other Description:

 

 

 

Professional Notes

 

 

 

 

 

PAIN:

Location

 

Constant       or         Intermittent

Time of day it’s worse

 

Better or worse with cold?

Better or worse with heat?

Better or worse with pressure?

 

Pain intensity 0-10

Does pain move?

Better or worse with activity?

 

Is there a heavy feeling?

Is the pain sharp and stabbing?

Is the pain dull and achy?

What is its duration?

 

 

Explain:

 

 

 

Professional Notes:

 

 

 

 

 

If you have stomach pain, does the pain…

 

Occur within 1-2 hours after eating

 

Occur after eating fried foods?

 

Awaken you at night?

 

Go away with an antacid?

 

Go away after a bowel movement?

 

Cause a loss of appetite?

Explain:

 

 

 

 

Professional Notes:

 

 

 

 

 

 

 

THIRST

 

Thirsty

 

No thirst, but drinks lots anyway

 

Prefer cold drinks

 

Absence of Thirst

 

Dry Mouth

 

Prefer room temperature drinks

 

Thirst with little desire to drink

 

 

 

Prefer hot drinks

What do you drink throughout the day?

Quantities:

1.

 

2.

 

3.

 

4.

 

5.

 

6.

 

7.

 

8.

 

Professional Notes:

 

 

 

 

APPETITE and DIGESTION (Check those that apply)

 

Rapid hungering

 

Indigestion

 

Loss of taste

 

Poor appetite

 

Acid Reflux

 

Canker sores

 

Hungry,

 but no desire to eat

 

Preference for salty food

 

Toothaches

 

Not hungry,

but desire to eat

 

Preference for fatty foods

 

Halitosis

 

Nausea

 

Preference for sweets

 

Diverticulitis

 

Vomiting

 

Bitter taste in mouth

 

Undigested food in stool

 

Bloating

 

Sweet taste in Mouth

 

Eating Disorder

 

Gas/ flatulence

 

Sour taste in mouth

 

Other:

Do you consider your weight to be:  

Normal, Overweight, or Underweight?

How many pounds would

you like to gain or lose?

What is a typical Breakfast for you?

 

 

 

What is a typical Lunch for you?

What is a typical Dinner for you?

 

 

 

What are typical snacks you eat?

What foods do you crave?

 

 

 

What foods do you avoid?

Explanations:

 

 

 

 

Professional Notes:

 

 

 

 

 

 

 

 

 

URINATION

 

Frequent

 

Burning

 

Cloudy

 

Foul Smell

 

Difficult start

 

Large amount

 

Urgent

 

Painful

 

Dark Color

 

Bloody

 

Incontinence

 

Small amount

 

Kidney stones

 

History of bladder

or kidney infection

 

Other:

# of times / day

 

# of times / night

Explain:

 

 

Professional Notes:

 

 

 

 

 

 

BOWEL MOVEMENT:

 

Constipation

 

Watery

 

Thin

 

With Mucous

 

Black

 

Diarrhea

 

Incomplete

 

Formed

 

With Blood

 

Yellow

 

Loose

 

Hard & Dry

 

Strong Smell

 

Light to dark brown

 

Green

# of bowel movements per day:

 

Explain:

 

 

Professional Notes:

 

 

 

 

UPPER RESPIRATORY:

 

Chronic Cough

 

Thick sputum

 

Sore throat

 

Sinus infection

 

Sinus headache

 

Bronchitis

 

Green sputum

 

Post nasal drip

 

Swollen sinus

 

Wheezing

 

Profuse, watery sputum

 

Yellow sputum

 

Dry sinus

 

Congestion

 

Snoring

Explain:

 

 

Have you ever been allergy tested?                   YES         NO

If yes, what substances did you test positive for?

 

 

Professional Notes:

 

 

 

 

VISION

 

Loss of vision

 

Eye pain

 

Eyelid drooping

 

Macular Degeneration

 

Burning eyes

 

Dry eyes

 

Red eyes

 

Glaucoma

 

Flashes / Floaters

 

Discharge from eyes

 

Excessive tears

 

swollen

 

Cataracts

 

Double vision

 

Itchy eyes

Explain:

 

 

Professional Notes:

 

 

 

 

HEARING:

 

 

Hearing Loss

 

High Pitched Tinnitus

 

Clogged Ears

 

Vertigo

 

 

Ear Pain

 

Low Pitched Tinnitus

 

Drainage

 

Other:

Explain:

 

 

Professional Notes:

 

 

 

 

 

SKIN

 

Rashes

 

Psoriasis

 

Skin ulcers

 

Bronchitis

 

Eczema

 

Acne

 

itching

 

Pneumonia

 

Rosacea

 

Prickly heat

 

Dry skin

 

Oily skin

If so, where?

 

Professional Notes:

 

 

 

 

PERSPIRATION (check those that apply)

 

Too easily

 

Frequent sweating

 

Feet Sweating

 

Too little

 

Night Sweats

 

Absence of Sweating

 

Profuse sweating

 

Palms Sweating

 

Other

Describe:

 

 

Professional Notes:

 

 

 

TEMPERATURE (Check those that apply):

 

Feel cold easily

 

Alternating hot and cold

 

Cold weather bothers you

 

Feel hot easily

 

Experience hot flashes

 

Hot weather bothers you

 

Cold Hands

 

Sensitive to weather changes

 

Damp weather bothers you

 

Cold feet

 

Sensitive to barometric change

 

Windy weather bothers you

Describe:

 

 

Professional Notes:

 

 

 

SLEEP:

 

Wake refreshed

 

Awakened by pain

 

palpitations

 

Difficulty falling asleep

 

Sudden awakening

 

Night sweats

 

Difficulty in falling back asleep

 

Nightmares

 

Can’t stop thinking

 

Awakened easily

 

Susceptibility to fear & fright

 

Restlessness

 

Difficulty waking

 

Anxiety

 

Drowsiness during the day

 

Early morning waking

 

Irritability

# of hours of sleep/night

 

Dream Disturbed sleep

 

Worry

 

Unwanted movements

 

Poor memory

Explain:

 

 

Professional Notes:

 

 

 

 

 

REPRODUCTIVE (Women only)

Age of first Menses:

 

Are you still having regular monthly menstrual periods?

If no, when & why did it stop?

 

Are you now or have you ever

 taken the birth control pill?

If so, when?

Have you ever               

had a miscarriage?

If yes, how many Miscarriages,

and when?

Do you regularly have

the cancer test of the cervix?

Date of last test:

How many children

born alive?

How many

cesarean operations?

Explain any complications of pregnancy:

 

 

Do you have recurring yeast infections?

How many days

per cycle?

How many days

does it last?

Is your cycle regular?

 

Is color of flow…

Pale red?

 

Dark red?

Bright red?

Purplish?

Do you ever

have clots?

If yes, are color of clots…

Pale red?

Dark red?

Bright red?

Purplish?

Is amount of flow…

Very light?

Light?

Normal?

Heavy?

Very heavy?

Is Quality of flow…

Thin?

Normal?

Thick?

Do you have bleeding

between your periods?

If yes, how often

and amount:

Do you have any type of pain?

Before flow?

During flow?

After flow?

Is the pain located in the …

Head?

Chest?

Abdomen?

Side of chest?

Breasts?

Lower back?

Is the pain relieved by…

Heat?

Cold?

Pressure?

Is the pain aggravated by…

Heat?

Cold?

Pressure?

Is the pain…

Dull?

Sharp and stabbing?

A burning sensation?

A “bearing down” sensation?

Emotions around period…

 

Depression?

Irritability?

Anger?

 

Sadness?

Crying?

Do these emotions come…

Before flow?

During flow?

After flow?

Professional Notes

 

 

 

 

 

 

 

 

 

REPRODUCTIVE (Men only)                

Have you ever had Loss of sexual function?

 

If yes, for how long?

Treatment for genitals?

 

Hernia (rupture)?

Prostate Disease?

Professional Notes:

 

 

 

 

 

ENERGY

 

Low

 

Exhausted

 

Nervous energy

 

Changes in memory

 

Up & Down

 

Hyperactive

 

Abundant

 

Normal

Libido:                      Low?                     Average?                      High?

Explain

 

 

 

 

Professional Notes:

 

 

 

 

 

 

EMOTIONS

 

Depression

 

Panic Attacks

 

Worry

 

Angry

 

Irritability

 

Sadness

 

Sensitive

 

Overly Excited

 

Anxiety

 

Memory Problems

Explain:

 

 

 

 

Professional Notes:

 

 

 

 

 

 

 

Do you frequently have any of the following:

 

Bleeding gums

 

Hoarseness

 

Spells of Dizziness

 

Weakness of arms or legs

 

Halitosis (bad breath)

 

A sore tongue

 

Fainting Spells

 

Hair loss

 

Trouble swallowing

 

Nosebleeds

 

Edema/ swelling

 

Convulsions

 

Mouth Sores

 

 

 

 

 

 

Explain:

 

 

 

Professional Notes: