Patient Medical History Intake Form (Page 2 of 2) in pdf

PATIENT SYMPTOM SURVEY

Patient Name:

Date:

GENERAL

REPRODUCTIVE SYSTEM

CHEST

ARMS & HANDS

PAST NOW

� � fatigue

� � painful intercourse

� � chest pain

� � pain in upper arm

� � sleep problems

� � prostate problems

� � shortness of breath

� � pain in forearm

� � swollen glands

� � sexual problems

� � pain in hands

� � pain around ribs

� � hot/cold intolerance

� � loss of sex drive

� � pain in fingers

MUSCULOSKELETAL

� � frequent headaches

� � genital infections

� � pinched nerve in arm

� � weight loss

birth control method: ________

� � pinched nerve in hand

� � joint swelling

� � weight gain

� � pins & needles in arm

� � muscle cramps

WOMEN ONLY

� � fever or chills

� � pins & needles in hand

� � neck pain

� � cramps

� � allergies

� � fingers go to sleep

� � shoulder pain

� � PMS

� � hands cold

� � tennis elbow

EMOTIONAL

� � irregular periods

� � swollen joints in fingers

� � arm pain

� � nervousness

Are you pregnant?

� � arthritis in fingers

� � hand sensations

� Yes � No

� � anxiety or worry

� � loss of grip

� � loss of grip strength

date of last period ____

� � frequent crying

� � mid-back pain

HIPS, LEGS & FEET

# pregnancies ________

� � irritability

� � rib pain

# of miscarriages ______

� � anger

� � low back problems

� � pain in buttocks (R/L)

� � difficult labor

� � tension

� � hip pain

� � pain in hip joint (R/L)

� � breast problems

� � mood swings

� � foot problems

� � pain down leg (R/L)

� � fear

� � leg cramps

� � pain down both legs

HEAD

� � restlessness

� � knee pain

� � leg cramps

� � confusion

� � headache

� � ankle weakness

� � pins & needles in legs

� � depression

� � entire head

� � tingling foot

� � numbness of leg (R/L)

� � suicidal thoughts

� � back of head

� � numbness of feet (R/L)

LOW BACK

� � forehead

� � numbness of toes

NERVOUS SYSTEM

� � temples

� � low back pain

� � feet feel cold

� � dizziness

� � migraine

� � low back pain is worse

� � cramps in feet (R/L)

� � head feels heavy

� � fainting

when:

� � swollen ankles (R/L)

� � paralysis

� � loss of memory

� working

� � swollen feet (R/L)

� � tremors

� � light-headedness

� lifting

� � painful joints in toes

� � numbness/tingling

� � fainting

� stooping

� � pain in foot (R/L)

� � convulsions

� � light bothers eyes

� standing

� � pain in knee (R/L)

� � loss of smell

� � memory loss

� sitting

HEART/LUNG

� � muscle weakness

� � loss of taste

� bending

� � loss of balance

� coughing

� � chest pain

GASTROINTESTINAL

� � dizziness

� � pinched nerve

� � high blood pressure

� � change in appetite

� � slipped disk

� � low blood pressure

EYES, EARS, NOSE, THROAT

� � thirst

� � muscle spasms

� � persistent cough

� � nausea

� � eye pain

� � arthritis

� � hard to breathe

� � vomiting

� � dry eyes

� � coughing blood

MID BACK

� � diarrhea

� � blurred vision

� � coughing phlegm

� � earache

� � constipation

� � mid back pain

� � irregular heartbeat

� � gas

� � ear discharge

� � pain between shoulder

� � varicose veins

� � ringing in ears

� � hemorrhoids

blades

� � ankle swelling

� � belching

� � hearing loss

� � sharp stabbing pain

SKIN

� � nosebleeds

� � heartburn

� � muscle spasms

� � abdominal pain

� � hoarseness

� � easy bruising

SHOULDERS

� � bloody/black stools

� � problems swallowing

� � dry skin

� � indigestion

� � sore throat

� � pain in shoulder joint

� � itching

� � jaw tight or sore

� � pain across shoulders

� � boils

URINARY

� � dental problems

� � bursitis (R/L)

� � rashes

� � painful urination

� � arthritis (R/L)

� � excessive sweat

NECK

� � frequent urination

� � tension in shoulders

� � hair changes

� � difficult urination

� � pain in neck

� � pinched nerve

� � incontinence

� � pain with movement

� � limited range of motion

� � bed wetting

� � pinched nerve in neck

� � dark urine

� � stiff neck

� � muscle spasms in neck

� � frequent infections

� � prostate problems

� � arthritis in neck

PATIENT SIGNATURE

Acupuncture Arts East

62 Brown Street, Merrimack Medical Center, Suite 402, Haverhill, MA 01830

t: 978-372-4771

Patient Medical History Intake Form Page 2

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