Patient Health History

Step 1 of 13

Personal Information
Date
MM slash DD slash YYYY
Name
Age
Date of Birth
MM slash DD slash YYYY
Parents Name (if minor)
Address
Street Address City State Zip
Phone:
Home
Work
Cell
Ht
Wt
Sex
- M
- F
Marital Status
Children (ages)
E-mail
I prefer to be contacted at: (check one)
- Home
- Work
- Cell
- E-mail
Occupation
Employer
In case of emergency, call: Name
Phone
How did you hear about us?
Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally and emotionally. Please complete this questionnaire as thoroughly as possible. Print all information and indicate areas of confusion with a question mark. Thank You!
When and Where did you last receive health care?
For what reason?
Please identify the health concerns that have brought you to Healing Alternatives, Inc., in order of importance, below:
Condition/ Chief Complaint
Past Treatment
1.
2.
3.
4.
Have you ever been diagnosed with a serious disease or condition?
If yes, please describe
When was the last time you felt really healthy? (Physically, Mentally, and Emotionally)

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FAMILY HISTORY (Please list family health problems)
Mother
Father
Brothers/Sisters
Grandparents
General Health Practices
Smoking:
Do you smoke now?
If so, how much per day?
Did you ever smoke?
If so, how much for how long?
When did you quit?
Teeth:
Do you have any Metal fillings?
Any root canals?
Use Fluoride toothpaste?
Patterns and Pivot Points:
A Pattern is something that has been consistent and true for you over time. Common Patters might be hormone symptoms, fatigue, anxiety or poor sleep, etc. Please indicate your patterns below.
A Pivot Point is some event, or timeframe when your health was changed significantly for the better, or worse. Some Pivot Points are positive, meaning you got/felt better. Other Pivot Points are negative (things started or got worse). Common Pivot Points are injuries, illnesses, major stressors, getting pregnant, childbirth, menopause, etc. Please indicate any positive or negative Pivot Points that come to mind below.

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Positive Pivot Points: I felt good, or got better when:
Negative Pivot Points: I got worse, or everything started when:
Exposures:
Exposures:
Do you have your home or yard chemically treated?
Does your occupation involve the use of toxic chemicals or metals?
When using household cleaning items, do you utilize organic or chemical free agents?
Do you use all natural or organic personal care items, such as shampoo and lotions?
Do your hobbies expose you to chemicals or toxins? Examples: Golfing exposes people to chemically treated grass; Swimming exposes you to chemicals like chlorine.
Have you ever been exposed to mold that you know of? A moldy home, cleaning a large amount of mold at one time, etc?
- Yes
- No
If Yes, please explain these circumstances.

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Please indicate which of the following foods you eat and how often.
Starches (Rice, Potato, pasta, bread)
Never Sometimes Frequently
Grains (Rice, wheat, buckwheat, Quinoa, Amaranth etc)
Never Sometimes Frequently
Beans & Legumes
Never Sometimes Frequently
Nuts & Seeds (Other than Peanuts)
Never Sometimes Frequently
Gluten-containing foods - (Wheat, oats, rye, barley, spelt, kamut, triticale)
Never Sometimes Frequently
Dairy (Milk, cheese, yogurt, ice cream)
Never Sometimes Frequently
Soy and Soy products
Never Sometimes Frequently
Corn and Corn Products (Including High Fructose Corn Syrup)
Never Sometimes Frequently
Eggs (White and/or Yolk)
Never Sometimes Frequently
Peanuts
Never Sometimes Frequently
Nightshades (tomato, potato, eggplant, chili pepper, bell peppers)
Never Sometimes Frequently
Baker’s Yeast (in baked goods, breads, etc.)
Never Sometimes Frequently
Please list the three best and worst foods you eat on regular basis.
Best Worst

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Please label all PROBLEM AREAS as 1, 3, OR, 5. (1=MILD, 3=MODERATE, 5=SEVERE)
Lack of Energy
Headaches
High Blood Pressure
Backaches
Weight Problems
Low Blood Pressure
Heart burn
Low Sex Drive
Frequent Infections
Poor Circulation
Cold Hands and Feet
Diabetes
Food Allergies
Hypoglycemia
Sinus infections
Gas, Bloating
Water Retention
Environmental Allergies
Diarrhea
Constipation
Painful Joints
Irritability
Loss of Memory
Menopause Problems
Anxiety
Osteoporosis
Menstrual Problems
Depression
Prostate Problem
Rashes/ Skin Problems
Irregular Heartbeat
Asthma
Sleep Problems
Hemorrhoids
Yeast Infections
Cancer
Spasms/Cramps
Pain
Pain– If so Where?
Do you have any comments or concerns?
I HAVE READ THE ABOVE INFORMATION AND CERTIFY IT TO BE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
(Please initial)
Payment Your payment will be due at time of service. We accept cash, major credit cards, and checks. Please be advised we charge a $35.00 fee for a bounced check.

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Cancellation Policy Please give 24 hours’ notice if you need to cancel or reschedule. Missing your scheduled appointment time compromises the effectiveness of your treatment plan, and keeps others from being able to make an appointment in that time slot. You may be charged a “no show” fee of $20 if you fail to cancel your appointment in a timely manner. Thank you for your understanding.
Privacy Policy Your privacy is important to us. We will never share your private healthcare information with an outside source unless we have your written consent or otherwise required by law. We do not transmit health related information electronically.
Acupuncture Informed Consent
Acupuncture involves the insertion of pre-sterilized, disposable needles into specified points on the body in order to affect a change. In most cases the changes are pleasant and lead to healing. In some cases, there may be side effects such as: bruising, discomfort, redness, slight bleeding, fainting, temporary pain/ discomfort/ dizziness or weakness, and temporary aggravation of symptoms existing prior to treatment. While this outlines the most commonly occurring adverse effects of treatment, other effects and risks may occur. Please be in communication with your practitioner if you have any concerns. We make no attempt to replace your primary care doctor. We encourage you to see your doctor when necessary and to have routine checkups. We are happy to refer you to the appropriate medical professional should the need arise.
Signing below indicates that you have completed the form as accurately as possible. Additionally, you understand that it is your responsibility to inform your practitioner of any health changes prior to each treatment. At any time, you or your practitioner may refuse treatment.
Printed name of patient
Date
MM slash DD slash YYYY
Patient/Guardian Signature

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Step 1 of 13

Personal Information

Please take me through a typical day in your diet. What time do you eat, what do you typically eat?

Please indicate which of the following foods you eat and how often.

Acupuncture Informed Consent

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