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Taking A History
Additional Medical Information
Previous diseases
Childhood diseases
Strep
Chicken Pocks
Mumps, etc.
Polio
Asthma
TB
Neumonia
Bronchitis
Diabtetes
Hypertension
Gall Bladder, Kidney diseases
Epilepsy
STD
Cancer
Stroke
Ulcers
Chronic fatigue
Other
Allergies and Their Reactions
Food
Chemical
Environment
e.g. pollen, dust, grass, smoke, pets, mold
Medications
Current drugs and medications
Current herbs and vitamins
Other alternative "medications"
Nutritional supllements
Over the counter drugs and products
Surgical history
removal of organs
corrective surgeries
injury related
Obstetric history
pregnancies
births
Accidents
What
When
Social Information
Travel Frequency
local and remote diseases
parasites
Environment hazard exposure
home, school, Job, etc.
mold exposure
Ocupation
Exercise
Diet
Substance use
Coffee
Tobaco
Drugs
Alcohol
Home life and family
Hobbies and other activities
Daily routine
Chief Complaint
How the patient describes their problems
History of complaint
When it started / how long present
Location of pain
Severity of pain
Frequency of pain
constant or intermitent
What makes pain better or worse
Interventions to date and results
Doctor visits
Medicines
Herbs
Other acupuncturists
Personal Information
Name
Age
Sex
Address, Phone, Email, etc.
Emergency Information
Family Medical History
Parents
Grandparents
Children
Siblings
If dead
when
why
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