Shelley's Kneedles & Knots, Acupuncture and Massage Health History Intake Form
General Information
Name:_______________________________________________________ Date:_______________________
Mailing Address:________________________________ Date of Birth: (dd/mm/yr)______________________
Town/City:________________________________ Prov.______________ Postal Code:___________________
Home Phone:____________________ Work Phone:_________________ Cell Phone:______________________
Email:_____________________________________________ Occupation:______________________________
Height:________ Weight:__________ Max. Weight:____________ When:_________________________
How did you hear about this clinic:__________________________________ Referred By:___________________
Focus (list Major complaints in order of importance)
| Complaint | Since | Causes |
Review of Symptoms: Only mark if a problem 1=occasional difficulty 2=frequent difficulty 3=regular difficulty
_____ weight loss/gain _____fatigue ______hair loss
______sexual difficulties _____ poor endurance ______ nervousness
______ depression _____ insomnia ______ nightmares
_____ muscle tension _____ muscle cramps ______ numbness
_______ tingling _____ cold hands/feet ______sweaty hands/feet
______blackouts _____ itching ______ rashes
_______ acne _____ eczema ______psoriasis
______ warts _____ change in mole ______ bruise easy
______headaches _____migraines ______ fevers
_______ dizziness _____ ringing in ears ______ earaches
_______ blurry vision _____ eyestrain ______ nasal congestion
_______ sinus pressure _____ nose bleeds ______ hayfever
______ swollen glands _____mucous problems ______ sores in mouth
______ coated tongue _____ bad breath ______ sore throats
______ dental problems _____ neck pains ______ cough
_______ difficulty breathing _____ coughing blood ______ heart palpitations
_______ chest pains _____ breast lumps/pain ______ abdominla pain
______ gas _____nausea/vomitting ______ difficult digestion
______ fatty food aggravate _____constipation ______diarrhea
______thin stool _____straining
______ number of bowel movements per day is this a change____________________________
______ hemorrhoids ____ bloody/black stools ______night urination
_____urinary problems ____burning on urination _____ bladder/kidney infection
_____ bedwetting ____ blood in urine _____ back pain
_______ leg sweling ____bone/joint pain _____ arm pain
______ leg pain ____ joint swelling _____ varicose veins
Write the approximate year that you incurred any of the following:
______ anemia _______arthritis(osteo/rheumatoid) ______ asthma
______ blood transfusion ________ bronchitis ______ cancer
______ chicken pox ______ colitis ______ Crohn's
________ diabetes ______ diptheria ______ drug reactions
______ epilepsy ______ fibromyalgia _______ gallstones
______ heart attack ______ heart disease ______ hepatitis
______ HB pressure _______HIV/AIDS ______ hives
______ hpoglycemia _______ jaundice _______ kidney stones
_______ IBS ______LB pressure ______ measles(German/Red)
_______mental problems _______ MS _______mumps
______ obesity ______ parasites _______ pneumonia
_______rheumatic fever _______ skin boils ______ syphilis
______ stroke _______ TMJ _______tuberculosis
_______ulcer ______whooping cough _______ phlebitis
Personal Physician:___________________________ Telephone:_________________
Date of last physical:_______________________________________
Are you allergic to medicines? Which ones?
______________________________________________________________________________________________
Are you allergic to foods? Which ones?
______________________________________________________________________________________________
Are you allergic to the environment? What?
______________________________________________________________________________________________
Please list any medications, prescriptions, or over the counter medicines that you take:
______________________________________________________________________________________________
Please list any regular vitamins, minerals, or herbal supplememnts that you take:
______________________________________________________________________________________________
Please list any major operations that you have had, and the year:
______________________________________________________________________________________________
Please list any major injuries or accidents that you have had and the year
(please include all breaks, sprains and dislocations in this as well):
_______________________________________________________________________________________________
Please list any major illnesses or hospitalizations that you have had:
_______________________________________________________________________________________________
Please list any other medical diagnosis that you have had from past or present:
_______________________________________________________________________________________________
Exercise Information
How often do you exercise weekly? __________________________________________________________________
What form of exercise do you do?____________________________________________________________________
How long do you exercise for?_______________________________________________________________________
I certify that the information provided in this form is true and accuratly reflects my past and present health status.
Signature:__________________________________________ Date:________________
