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Acupuncture Questionnaire
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* Indicates required question
Email
*
Your email
Legal Name
*
Your answer
Preferred Name
Your answer
Date
*
MM
/
DD
/
YYYY
Date of Birth
*
MM
/
DD
/
YYYY
Birth Sex
Female
Male
Other:
Clear selection
Pronoun Preference
He
She
They
Ze
Other:
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When did you last receive health care? And for what reason did you receive care?
Your answer
Please describe the primary health concerns that have brought you to our clinic in order of importance below (please list the condition and how it affects you)
Your answer
Food allergies (please include reaction)
Your answer
Drug or medication sensitivities/allergies (please include reaction)
Your answer
List any medications (prescribed over-the-counter) you are currently taking
Your answer
List any vitamins, herbs, and/or supplements you are currently taking
Your answer
Are you pregnant?
Yes
No
Maybe
Clear selection
If you are pregnant, how far along are you?
Your answer
Do you have any infectious diseases?
Yes
No
Maybe
Clear selection
Family health history (check those applicable)
Father
Mother
Brothers
Sisters
Spouse
Children
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Mental Illness
Asthma/Hay Fever/Hives
Kidney Disease
Father
Mother
Brothers
Sisters
Spouse
Children
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Mental Illness
Asthma/Hay Fever/Hives
Kidney Disease
Height
Your answer
Current weight
Your answer
Past Max Weight and Date
Your answer
Most recent blood pressure reading and when it was taken
Your answer
Childhood Illnesses
Scarlet Fever Diptheria
Rheumatic Fever
Mumps
Measles
German Measles
Chicken Pox
Immunizations (please choose those you have had , or had reactions to)
Polio Tetanus
Measles/Mumps/Rubells
Pertussis
Diptheria
Hib
Hepatitis B
Other:
Hospitalizations and Surgeries (please describe the reason and date for each)
Your answer
X-Rays/CAT Scans/MRI's/NMR's/Special Studies (please describe the reason and date for each
Your answer
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