General Health History Form General Health History and Intake Form 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 ContactsEmergency Contact's Full Name* Emergency Contact's Phone*Primary Physician's Full Name* Primary Physician's Phone*All About YouDate of Birth* Month Day Year 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 HistoryNext to each illness/condition that you have experienced, enter details and specific datesCancer Diabetes Hepatitis High Blood Pressure Heart Disease Rheumatic Fever/Childhood Diseases Thyroid Disease Other… SurgeriesSignificant Trauma (Auto Accidents, Falls, etc.)Allergies (Drugs, Metal/Chemicals, Foods)Medicines Taken in the Last Three Months (Vitamins, Drugs, Herbs)Personal InformationDo you exercise regularly? If Yes, please describeHave you ever been on a restricted diet? If Yes, what kind and why?Average Daily Diet – Please describe in detailMorningAfternoonEveningDo 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 monthsGeneral Fevers Sweat Easily Bleed or Bruise Easily Change in Appetite Poor Sleeping/Insomnia Chills Weight Loss/Gain Strong Thirst Fatigue Night Sweats Sudden Energy Drop Cravings If sudden energy drop, What time of day? If Cravings, for what? Skin and Hair Rashes Itching Change in Hair/Skin Texture Ulcerations Eczema Hives Loss of Hair Acne Recent Moles Other If Other, please explain. Head/Eyes/Ears/Nose/Throat Dizziness Glasses Poor/Blurry Vision Cataracts Eye Strain Eye Pain Eye Surgeries Color Blindness Floaters (Spots in Front of the Eyes) Night Blindness Tinnitus (Ringing in the Ears) Earaches Poor Hearing/Hearing Aids Headaches/Migraines Sinus Problems Teeth Grinding Concussions Nose Bleeds Jaw Clicks Recurrent Sore Throats Sores on Lips/Tongue Other If Eye Surgeries, What and When? If Headaches/Migraines, where located? If Other, please explain. Cardiovascular High Blood Pressure Low Blood Pressure Irregular Heartbeat Cold Hands/Feet History of Blood Clots Difficulty Breathing Swelling of Hands/Feet Phlebitis Chest Pain Fainting Other If Other, describe. Respiratory Cough Bronchitis Difficulty Breathing when Lying Down Asthma Production of Phlegm Coughing Blood Wheezing Pneumonia Pain with Deep Breath Other If Phlegm, what color? If Other, describe Gastrointestinal Nausea Vomiting Diarrhea Constipation Gas Belching Black Stools Blood in Stools Indigestion Bad Breath Rectal Pain Hemorrhoids Bleeding Gums Abdominal Pain/Cramps Chronic Laxative Use Other If Other, describe: Genitourinary Pain Upon Urination Frequent Urination Blood in Urine Urgency to Urinate Unable to Hold Urine Night Urination Kidney Stones Decrease in Flow Impotency/Infertility Sores on Genitals Other If Other, describe: If Night Urination, How many times? ReproductiveAre you pregnant? No Yes Is it possible that you could be pregnant? No Yes Number of PregnanciesNumber of Live BirthsNumber of MiscarriagesNumber of AbortionsNumber of Premature BirthsDate of Last PAP Age of First MensesDuration 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 MusculoskeletalPlease check areas where you experience pain Neck Back/Spine Hand/Wrist Shoulder Elbow Knee Ankle Hips Muscle Weakness Numbness Parathesias (Tingling) Other If Other, describe: NeuropsychologicalCheck all that you experience. Seizures Dizziness Loss of Balance Lack of Coordination Poor Memory Concussion Depression Anxiety Bad Temper Easily Susceptible to Stress Been treated for emotional challenges? No Yes Have you ever considered or attempted suicide? No Yes Any other neuropsychological issues?
