General Health History Form Marlborough Wellness Center

LAST Name*

FIRST Name*

Street Address*

City/Town*

State*

Zip Code*

Home Phone*

Day Phone*

Your Email*

Occupation

How did you hear about MWC?

Your Medical Contacts

Emergency Contact's Full Name*

Emergency Contact's Phone*

Primary Physician's Full Name*

Primary Physician's Phone*

All About You

Date of Birth*

Your Age*

Have you been treated by Acupunture or Oriental Medicine before?*

No
Yes

Main concern(s) you would like us to address*

When did this begin?

How does it interfer with your daily activities (ie: work, sleep, sex)?

Have you been given a formal diagnosis for this problem?

No
Yes

What other treatments have you tried?

Family Medical History

Diabetes
Cancer
High Blood Pressure
Heart Disease
Stroke
Seizures
Asthma
Allergies
Other

Check all that apply.

if Other, describe.

Your Past Medical History

Next to each illness/condition that you have experienced, enter details and specific dates

Cancer

Diabetes

Hepatitis

High Blood Pressure

Heart Disease

Rheumatic Fever/Childhood Diseases

Thyroid Disease

Other...

Surgeries

Significant Trauma (Auto Accidents, Falls, etc.)

Allergies (Drugs, Metal/Chemicals, Foods)

Medicines Taken in the Last Three Months (Vitamins, Drugs, Herbs)

Personal Information

Do you exercise regularly? If Yes, please describe

Have you ever been on a restricted diet? If Yes, what kind and why?

Average Daily Diet - Please describe in detail

Morning

Afternoon

Evening

Do you currently smoke?

No
Yes

Yes: How much do you smoke per day?

NO: Have you ever smoked, and, if so, how much per day and when did you quit?

Please describe any use of drugs for non-medical purposes.

How many caffeinated beverages do you drink per day?

How much water do you drink per day?

How much alcohol do you drink per day?

Are there any other concerns you would like us to address?

In all the areas listed below, please check if you have experienced any symptoms in the past 3 months

General

If sudden energy drop, What time of day?

If Cravings, for what?

Skin and Hair

If Other, please explain.

Head/Eyes/Ears/Nose/Throat

If Eye Surgeries, What and When?

If Headaches/Migraines, where located?

If Other, please explain.

Cardiovascular

If Other, describe.

Respiratory

If Phlegm, what color?

If Other, describe

Gastrointestinal

If Other, describe:

Genitourinary

If Other, describe:

If Night Urination, How many times?

Reproductive

Are you pregnant?

No
Yes

Is it possible that you could be pregnant?

No
Yes

Number of Pregnancies

Number of Live Births

Number of Miscarriages

Number of Abortions

Number of Premature Births

Date of Last PAP

Age of First Menses

Duration of Menses

Do you experience (Check all that apply)?

Irregular Periods
Spotting Between Periods
Heavy/Light Periods
Painful Periods
Clots
Vaginal Discharge
Vaginal Sores
Breast Lumps

Any changes in body/psyche prior to menses onset (PMS)?

Practice birth control (if yes, what kind?)?

Menopause: Age

Musculoskeletal

Please check areas where you experience pain

If Other, describe:

Neuropsychological

Check all that you experience.

Been treated for emotional challenges?

No
Yes

Have you ever considered or attempted suicide?

No
Yes

Any other neuropsychological issues?

Marlborough Wellness Center

General Health History Form

Gen Intake

Your Medical Contacts

All About You

Your Past Medical History

Personal Information

Average Daily Diet - Please describe in detail

In all the areas listed below, please check if you have experienced any symptoms in the past 3 months

Reproductive

Musculoskeletal

Neuropsychological