White Pine Acupuncture 247 Charlotte St., R3 • Asheville, NC 28801 • 828.545.2288

www.whitepineacupuncture.com

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Name: __________________________________________________________________________________________ Last, First How did you find out about us?____________________________________________________________________

Please circle your primary contact number below: Telephone: Home: ____________________Work: _____________________ Cell: ________________________

May White Pine leave a message on your answering machine? Yes No

May White Pine leave a message with a family member? Yes No

Mailing Address: _______________________________________________________________________ Street/PO Box

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City, State, Zip

Email address: _________________________________________________ Date of Birth: ___________

Emergency Contact: __________________________ Relationship to you: ________________________

Contact #_____________________

Please take your time to fill out this health history; the information you provide here often helps us to see connections that we might otherwise miss. Also, filling out this form can be useful in learning how to observe yourself in a way you may not be accustomed to doing. This awareness is an important aid to healing. This form asks about parts of your health history that may seem irrelevant at first. We find that there is very little that happens in any part of the body that is irrelevant to the health of the whole because we consider the body as a complex whole integrated by acupuncture channels. For example, a channel on the foot also connects to the hip, the abdomen, and the head. In this way, symptoms like foot pain and digestive problems could be related to the same source of disharmony. All fields are optional. Please know that any information you give in the following form is confidential and will be seen only by the acupuncturists of White Pine and by no other of its employees.

DATE:    ____/____/______      PATIENT  NAME:  ____________________________  2 of 8

Please circle any that apply to you: Surgical Implants Pacemaker HIV Hepatitis

Height___________ Weight__________ Age________ Place of Birth: __________________

Occupation___________________________________

Single / Married / Partnered / Dating / Separated / Divorced / Widowed

Please list your main symptoms or concerns and rate how intense (1-10) each is today.

10 is the worst discomfort you have ever felt; 1 is minor discomfort.

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b) _____________________________________ ___

c) _____________________________________ ___

d) _____________________________________ ___

e) _____________________________________ ___

(1-10) f) _____________________________________ ___

g) _____________________________________ ___

h) _____________________________________ ___

i) _____________________________________ ___

j) _____________________________________ ___

Please describe what each one of the above feels like.

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How much are the above disturbing your life? ___ (1-10) 10 is completely; 1 is almost not at all

When are your symptoms worse?_______________________________________________________________________

When are your symptoms improved?___________________________________________________________________

Rate your overall wellness: ___ (1-10) 10 is excellent; 1 is poor

Please list three things you would like to change about your health and well-being in order of importance. ____________________________________________________________________________________________________

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DATE:    ____/____/______      PATIENT  NAME:  ____________________________  3 of 8

Please list approximate dates and briefly describe any hospitalizations, surgeries, or major illnesses you have had.

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Please list approximate dates and briefly describe any significant life experiences that you would like to share

(e.g. car accidents, divorce, death in family, injury, assault).

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Please list any known medical conditions or diagnoses.

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Diet

Please list what you ate yesterday, along with the approximate time: Breakfast:____________________________________________________________________________________________ time

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____________________________________________________________________________________________________ Dinner:______________________________________________________________________________________________ time

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____________________________________________________________________________________________________ Does the above reflect your usual diet? ______If not, how is your usual diet different? ________________________ ____________________________________________________________________________________________________ Do you have any food cravings? Sweet Pungent Spicy Salty Sour Bitter Other_______________

DATE:    ____/____/______      PATIENT  NAME:  ____________________________  4 of 8

Lifestyle and Sensitivities

Allergies/Intolerances: Gluten Nuts Tree fruit Dairy Mushrooms Shellfish

Other__________________ Please list any dietary restrictions (e.g. vegan). ___________________________________________________________ Alcohol ______drinks per day/week Tobacco _________ per day/week TV/Video/Computer______hours per day Sleep ______average # of hours per night Coffee ______cups per day Soda ______cups (servings) per day/week Tea (iced/hot) ______cups per day Energy drinks ______servings per day Fast/convenience food __________________________________________ ______# meals or snacks per day/week List/describe

Exercise ________________________________________________________________ ______# times per day/week List/describe

________________________________________________________________ ______# times per day/week

List/describe

Rate your energy: ___ (1-10)

10 is bouncing off the walls; 5 is just enough to do what you need; 1 is almost none.

Please circle any weather sensitivities:

Weather changes Wind Heat Dampness Dryness Cold Other________________

Women Only Are you pregnant (current or possible)? Yes / No

________________________________# of pregnancies, please give approximate dates

________________________________# of live births, please give approximate dates

________________________________# of miscarriages, please give approximate dates

________________________________# of abortions, please give approximate dates

_________________________Age at first period

DATE:    ____/____/______      PATIENT  NAME:  ____________________________  5 of 8

Review of Systems

Please rate the intensity (1-10) of any persistent or otherwise bothersome symptom or condition you have experienced. Please check any symptoms you have experienced within the past month. 10 is the worst discomfort or disturbance you have ever felt; 1 is minor discomfort or disturbance.

Eyes (1-10) Approximate dates (if known) ☐___ Blurred vision_______________________________ ☐___ Dryness____________________________________ ☐___ Red, itchy, or painful_________________________ ☐___ Excessive tearing____________________________ ☐___ Poor night vision____________________________ ☐___ Spots or floaters_____________________________ ☐___ Double vision_______________________________ ☐___ Glaucoma__________________________________ ☐___ Cataracts___________________________________ ☐___ Other (describe)_____________________________ _________________________ Ears ☐___ Hearing loss________________________________ ☐___ Ringing____________________________________ ☐___ Earache____________________________________ ☐___ Discharge or fullness_________________________ ☐___ Other (describe)_____________________________ _________________________ Nose, Throat, and Mouth ☐___ Nasal congestion____________________________ ☐___ Swallowing/spitting phlegm_________________ ☐___ Allergies___________________________________ ☐___ Sinus infection______________________________ ☐___ Postnasal drip_______________________________ ☐___ Frequent cold/flu___________________________ ☐___ Nosebleed__________________________________ ☐___ Dry nose or mouth__________________________ ☐___ Sores or swellings___________________________ ☐___ Dental/gum problems_______________________ ☐___ Jaw tension/tightness_______________________ ☐___ Teeth grinding______________________________ ☐___ Facial pain__________________________________ ☐___ Dry or sore throat___________________________ ☐___ Strong thirst________________________________ ☐___ Difficulty swallowing________________________ ☐___ Loss of voice________________________________ ☐___ Other (describe)_____________________________ _________________________ Hot and Cold ☐___ Feel hot or cold _____________________________ ☐___ Cold hands or feet___________________________ ☐___ Desire hot or cold food/drink_________________ ☐___ Cold or hot spells___________________________ ☐___ Other (describe)_____________________________ _________________________

Head and Neck (1-10) Approximate dates (if known) ☐___ Vertigo_____________________________________ ☐___ Light-headed/fainting_______________________ ☐___ Headache/migraines ________________________ ☐___ Swellings___________________________________ ☐___ Tension/stiffness____________________________ ☐___ Other (describe)_____________________________ _________________________ Skin ☐___ Rashes or hives______________________________ ☐___ Acne_______________________________________ ☐___ Eczema/psoriasis___________________________ ☐___ Itching or redness___________________________ ☐___ Dry or oily skin _____________________________ ☐___ Abnormal sweating__________________________ ☐___ Easy bruising_______________________________ ☐___ Lumps or swellings _________________________ ☐___ Other (describe)_____________________________ _________________________ Chest ☐___ Difficulty breathing__________________________ ☐___ Frequent sighing____________________________ ☐___ Chronic cough _____________________________ ☐___ Coughing up blood__________________________ ☐___ Tight or stuffy chest__________________________ ☐___ Pneumonia/bronchitis_______________________ ☐___ Palpitations _____________________________ ☐___ Rapid/irregular heartbeat____________________ ☐___ Chest pain__________________________________ ☐___ High/low blood pressure_____________________ ☐___ Heart murmur______________________________ ☐___ Heart disease_______________________________ ☐___ Other (describe)_____________________________ _________________________ Body and Limbs ☐___ Heaviness or stiffness________________________ ☐___ Limited range of motion______________________ ☐___ Numbness or tingling _______________________ ☐___ Paralysis___________________________________ ☐___ Seizures or tremors__________________________ Pains (list below) ☐___ ___________________________________________ ☐___ ___________________________________________ ☐___ ___________________________________________ ☐___ Other (describe)_____________________________ _________________________

DATE:    ____/____/______      PATIENT  NAME:  ____________________________  6 of 8

Sleep and Energy ☐___ Difficulty falling asleep_______________________ ☐___ Difficulty staying asleep______________________ ☐___ Disturbing dreams___________________________ ☐___ Waking due to pain__________________________ ☐___ Night sweats________________________________ ☐___ Fatigue/energy drops________________________ ☐___ Restlessness/hyperactivity___________________ ☐___ Waking to urinate___________________________ ☐___ Other (describe)_____________________________ _________________________ Overall sleep quality: ___ (1-10) 10 is deeply restful; 0 is completely restless. Gastrointestinal ☐___ Low/excessive appetite______________________ ☐___ Bloating/flatulence__________________________ ☐___ Nausea or vomiting__________________________ ☐___ Belching/hiccupping________________________ ☐___ Heartburn or reflux__________________________ ☐___ Sluggish digestion___________________________ ☐___ Abdominal pain_____________________________ ☐___ Change in weight____________________________ ☐___ Altered taste________________________________ ☐___ Bad taste in mouth___________________________ ☐___ Bad breath _________________________________ ☐___ Diarrhea/loose stools________________________ ☐___ Constipation________________________________ ☐___ Difficult/Painful bowel movements____________ ☐___ Pebbly stool________________________________ ☐___ Laxative dependence_________________________ ☐___ Blood in stool_______________________________ ☐___ Tar-black/white stool________________________ ☐___ Mucous in stool_____________________________ ☐___ Undigested food in stool_____________________ ☐___ Other (describe)_____________________________ _________________________ _____ average # of bowel movements per day OR ______ average # of days between movements Urinary ☐___ Urinary tract/kidney infection________________ ☐___ Burning/hot urination_______________________ ☐___ Cloudy urine _______________________________ ☐___ Strong odor ________________________________ ☐___ Blood in urine ______________________________ ☐___ Incomplete emptying________________________ ☐___ Urgent urination __________________________ ☐___ Difficult/disrupted urination_________________ ☐___ Dribbling/Weak urination___________________ ☐___ Incontinence _______________________________ ☐___ Copious/frequent urination__________________ ☐___ Scant/infrequent urination___________________ Typical color_______________________

Reproductive (male and female) ☐___ Low or high libido___________________________ ☐___ Pain or itching of genitals_____________________ ☐___ Genital discharge or lesions___________________ ☐___ Other (describe)_____________________________ _________________________ Female ☐___ Menopause_________________________________ ☐___ Painful periods______________________________ ☐___ Irregular periods____________________________ ☐___ Heavy or light blood flow____________________ ☐___ Menstrual blood clots________________________ ☐___ Vaginal discharge___________________________ Describe:________________________________________ ☐___ Breast tenderness____________________________ ☐___ Breast lumps________________________________ ☐___ Painful intercourse__________________________ ☐___ Abnormal pap smear________________________ ☐___ Vaginal infections___________________________ ☐___ Uterine fibroids_____________________________ ☐___ Endometriosis_______________________________ ☐___ Other (describe)_____________________________ _________________________ Male ☐___ Impotence__________________________________ ☐___ Premature ejaculation________________________ ☐___ Nocturnal emissions_________________________ ☐___ Lumps in testicles___________________________ ☐___ Hernia_____________________________________ ☐___ Enlarged prostate____________________________ ☐___ Other (describe)_____________________________ _________________________ Mental/Emotional ☐___ Poor memory_______________________________ ☐___ Foggy headedness___________________________ ☐___ Difficulty focusing___________________________ ☐___ Depression_________________________________ ☐___ Mood swings_______________________________ ☐___ Irritability/frustration/anger_________________ ☐___ Difficulty relaxing___________________________ ☐___ Loneliness__________________________________ ☐___ Sensitivity__________________________________ ☐___ Shyness____________________________________ ☐___ Frequent crying_____________________________ ☐___ Worry or anxiety____________________________ ☐___ Compulsive behaviors_______________________ ☐___ Suicidal thoughts____________________________ ☐___ Eating disorder______________________________ ☐___ Other (describe)_____________________________ _________________________

DATE:    ____/____/______      PATIENT  NAME:  ____________________________  7 of 8

Family Health History

Self Mother Father Siblings Maternal G’mother

Maternal G’father

Paternal G’mother

Paternal G’father

Spouse Children

Adopted Good health Growth/ developmental disorders

Fertility disorders

Thyroid disorders

Kidney disorders

Heart disease

High blood pressure

Hepatitis/ Liver disorder

Alcohol/ drug abuse

Depression/ mental illness

Diabetes

Musculoskeletal disorder

Autoimmune disorder

HIV/ AIDS

Cancer / tumors

Bleeding disorder/anemia

Seizure/ tremor

Allergies

Other:

Deceased Please list cause.

Do you have any disorders or characteristics that you wish you had not inherited (including anything like the family chin or the family quick temper)?

____________________________________________________________________________________________________ Please share any other information or comments you feel are relevant.

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DATE:    ____/____/______      PATIENT  NAME:  ____________________________  8 of 8

Medications, Herbs, & Supplements

Please list all medications (prescription and over-the-counter) and supplements. If you attach a separate list of medications, please make sure that the dosage, purpose, and duration of use for each medication are all listed.

Dosage Reason How long Medications: ____________________________________________________________________________________________________

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Dosage Reason How long

Herbs: ____________________________________________________________________________________________________

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Dosage Reason How long Vitamins & Supplements: ____________________________________________________________________________________________________

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