Northport Wellness Acupuncture & Massage Therapy - History QuestionniareNOTE: Many factors must be considered in designing a complete health-buidling program. Treating the whole person requires attention to all symptoms and conditions. Often minor symptoms are major clues to delicate biochemical, energetic or somatic imbalances. Please complete the questionnaire as carefully as you can. This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to any person except when you have authorized us to do so.

Name: ___________________________________________________ Date: _____________________ Case NO: _________Address: __________________________________________________________ Home Phone: ________________________Cell Phone: _____________________________ Email Address: __________________________________________________Employer: ___________________________________________________ Business Phone: ____________________________Primary Care Physician & Phone: __________________________________________________________________________Occupation: ________________________________________ Referred by: ________________________________Age: _______ Date of Birth: _______________ M F M S D W Spouse Child

Is your condition due to an accident an illness Other ___________________________________________________Did your accident occur while at work? Yes No When ____________________________________________________Were you involved in an automobile accident? Yes No When _______________________________________________STATE your present complaint, injury or illness: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________When did it begin? (Date) _______________ Describe what caused it: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What makes it better? ______________________________________________________________________________________What makes it worse? ______________________________________________________________________________________Is it getting worse? Yes No Does it interfere with: Work Sleep Daily Routine Other Explain: _________________________________________________________________________________________________Who have you previously consulted about your present problems? _________________________________________________________________________________________________________________________________________________________Secondary Complaints: ____________________________________________________________________________________Previous Medical Care: ____________________________________________________________________________________Operations: Please indicate all surgeries, type and year: _________________________________________________________________________________________________________________________________________________________________Have you ever been advised to have any surgery which was not done? ____________________________________________Have you been hospitalized for anything other than surgery? ______________________________________________________

TREATMENT FOR OTHER CONDITIONS: ___________________________________________________________________________________________________________________________________________________________________________

PERSONAL HISTORY: Have you ever had/do you currently have: Scarlet Fever Jaundice Rheumatic Fever Gonorrhea/Syphilis Pneumonia Anemia Rectal Disease Gallbladder disease Pleurisy Epilepsy Bladder Disease Diabetes Pollo/Meningitis Nephritis Cancer Nervous Breakdown Food/Drug Poisoning TB/Angina Hay Fever/Asthma Boils/infections Heart Disease Hepatits Alcoholism High Blood Pressure Miscarriage Mental Disorder Drug problems A.I.D.S.

FAMILY HISTORY: Has your father or mother ever had: Cancer Stroke Scoliosis Kidney Disease Glaucoma TB Epilepsy Diabetes Mental Disorder Heart Trouble Asthma Ulcers Arthritis Alcoholism High Blood Pressre Drug problem Allergies Other: ____________________________________________Is there any familial disease tendency of which you are aware: ____________________________________________________

INJURIES: (Auto accidents, falls, etc.) _________________________________________________________________________ Broken Bones Concussion or Head Injury Dislocations Sprains Loss of Consciousness

Northport Wellness Acupuncture & Massage Therapy - Current & Former Conditions

Name: _______________________________________________________ Date: _____________________Underline current conditions. Put a check mark in the box for former conditons.

State duration, frequency, intensity and pain in the space beside current symptoms.

GENERAL SYMPTOMS SKIN Tremors Skin eruptions Bed wetting Headache Clammy skin Inability to control urine Fever Dryness Prostrate trouble Sweats Bruises easily Bladder trouble Fainting Boils Foul smelling urine Convulsions Rashes Discolored urine Loss of sleep Sensitive skin GASTROINTESTINAL Fatigue Hives or allergy Poor appetite Nervousness RESPIRATORY Excessive hunger Depression Chronic cough Difficult chewing Loss of weight Spitting up phlegm Belching or gas Forgetfulness Spitting up blood Nausea Dizziness Chest pain Gas Numbness or pain in arms, hands Difficult breathing Vomiting elbows, shoulders, hips, legs, Wheezing Vomiting blood knees, or feet CARDIOVASCULAR Pain over stomach Confusion Rapid beating heart Distention of abdomen Auto Immune Deficiency Slow beating heart Constipation Paralysis Irregular beating heart DiarrheaEYES, EARS, NOSE & THROAT High blood pressure Black stool Failing vision Low blood pressure Colon trouble Near sighted Pain over heart Hemorrhoids (Piles) Eye pain Previous heart stroke Intestinal worms Eye strain Hardening of arteries Liver trouble Cross eyed Swelling of ankles Gall bladder trouble Eye inflammation Poor circulation Jaundice Glaucoma Paralytic stroke Colitis Deafness Varicose veins Weight trouble Earache MUSCLE & JOINT FEMALE Ear noises Stiff neck Painful menstrual periods Ear discharge Pain between shoulders Excessive flow Nose bleeds Backache Hot flashes Nasal obstruction Painful tail bone Irregular cycle Nasal drainage Foot trouble Cramps or backache Loss of smell Hernia Previous miscarriage Sinus infection Spinal curvature Vaginal discharge Hay fever Faulty posture Vaginal pain Allergies Swollen joints Congested breast Sore Throat Stiff joints Breast pain Hoarseness Painful joints Lumps in breast Difficult speech Arthritis Menopausal symptoms Difficult swallowing Sore muscles Abnormal bleeding Loss of taste Weak muscles Reduced sexual energy Changes in tastes Walking problems Pregnancy Dental decay Sciatica Pregnancy complications Gum troubles GENITOURINARY MALE Tonsillitis Frequent urination Pain associated with genitals Asthma Scanty urine Reduced sexual energy Loss of smell Painful urination Premature ejaculation Frequent colds Blood in urine Seminal emission Enlarged thyroid Pus in urine Impotence Enlarged glands Kidney infection or stones Discharges

Northport Wellness Acupuncture & Massage Therapy

HABITS, DIET, MEDICINE, ALLERGIES

Name: _______________________________________________________ Date: _____________________

LAST PHYSICAL: Date: ________________ Practitioner: _______________________ Results: __________________

HABITS: Indicate below: Heavy, Moderate, Light, or None. If significant, comment.

Heavy Moderate Light None

Alcohol: Coffee: Tea: Tobacco: Exercise: Sleep: Appetite: Energy: Medication: Vitamins: Diet: Teeth problems: Drugs: Salt: Other: Stress: _______________________________________________ (Chemical, physical, psychological)

AVERAGE DAILY DIET

Morning:

Afternoon:

Evening:

Between Meals:

Are you now on (or have you undertaken) a restricted diet? Please describe and indicate when.________________________________________________________________________________________________________________________________________________________________________________________________

MEDICINES taken within the last two months (include vitamins, over-the counter drugs, herbs)________________________________________________________________________________________________________________________________________________________________________________________________

ALLERGIES: (Drugs, chemicals, foods. Type of reaction.)________________________________________________________________________________________________________________________________________________________________________________________________

Northport Wellness Acupuncture & Massage Therapy

Name: _______________________________________________________ Date: _____________________

FEMALES ONLYAre you or might you be pregnant? Yes No Maybe If yes, what month? ___________________________________What method of birth control do you use? __________________________________________________________________________Are you experiencing reduced sexual energies? Yes No Other difficulties? Yes NoExplain: ______________________________________________________________________________________________________Do you have regular PAP tests? Yes No How regular? ________________________________________________________

PLEASE CHECK OR EXPLAIN IF APPLICABLE:Menstrual CycleAge started: __________ Age stopped: __________ Irregular __________________________________________________________________________________ Painful __________________________________________________________________________________ Excess blood __________________________________________________________________________________ Lack of blood __________________________________________________________________________________ Dark __________________________________________________________________________________ Light __________________________________________________________________________________ Heavy clotting __________________________________________________________________________________ Water retention __________________________________________________________________________________ Painful breast __________________________________________________________________________________

Vaginal Discharge Liquid __________________________________________________________________________________ Yellow __________________________________________________________________________________ Thick __________________________________________________________________________________ Bad odor __________________________________________________________________________________ White __________________________________________________________________________________ Other __________________________________________________________________________________

Gynecological History of Operations: Ovaries __________________________________________________________________________________ Uterus __________________________________________________________________________________ Tubes __________________________________________________________________________________ Vagina __________________________________________________________________________________ Breast __________________________________________________________________________________ Other __________________________________________________________________________________

Pregnancy:Total Number: __________________________________________________________________________________Number of children: __________________________________________________________________________________Number of abortions: __________________________________________________________________________________Number of miscarriages: __________________________________________________________________________________Complications: __________________________________________________________________________________

MALES ONLYPLEASE CHECK OR EXPLAIN IF APPLICABLE: Reduced sexual energies: __________________________________________________________________________________ Premature ejaculation: __________________________________________________________________________________ Seminal emission: __________________________________________________________________________________ Discharges: __________________________________________________________________________________ Pain associated with genitals: __________________________________________________________________________________ Other: __________________________________________________________________________________