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Shelley's Kneedles & Knots, Acupuncture and Massage

Shelley's Kneedles & Knots, Acupuncture and Massage  Health History Intake Form

General Information


Name:_______________________________________________________     Date:_______________________

Mailing Address:________________________________     Date of Birth: (dd/mm/yr)______________________

Town/City:________________________________  Prov.______________      Postal Code:___________________

Home Phone:____________________  Work Phone:_________________   Cell Phone:______________________

Email:_____________________________________________    Occupation:______________________________

Height:________  Weight:__________  Max. Weight:____________  When:_________________________

How did you hear about this clinic:__________________________________    Referred By:___________________


Focus (list Major complaints in order of importance)


Complaint Since Causes


Review of Symptoms: Only mark if a problem  1=occasional difficulty  2=frequent difficulty  3=regular difficulty

_____ weight loss/gain                     _____fatigue                      ______hair loss

______sexual difficulties                 _____ poor endurance       ______ nervousness  

______ depression                          _____ insomnia                   ______ nightmares

_____ muscle tension                      _____ muscle cramps        ______ numbness    

_______ tingling                               _____ cold hands/feet        ______sweaty hands/feet

 ______blackouts                             _____ itching                     ______ rashes                          

_______ acne                                  _____ eczema                    ______psoriasis                      

______ warts                                  _____ change in mole        ______ bruise easy

______headaches                           _____migraines                 ______ fevers            

_______ dizziness                          _____ ringing in ears          ______ earaches                       

_______ blurry vision                     _____ eyestrain                  ______ nasal congestion           

_______ sinus pressure                _____ nose bleeds              ______ hayfever                    

______ swollen glands                  _____mucous problems      ______ sores in mouth

______ coated tongue                   _____ bad breath                ______ sore throats     

 ______ dental problems                _____ neck pains                ______ cough                             

_______ difficulty breathing           _____ coughing blood         ______ heart palpitations          

_______ chest pains                      _____ breast lumps/pain     ______ abdominla pain         

______ gas                                     _____nausea/vomitting       ______ difficult digestion

______ fatty food aggravate          _____constipation               ______diarrhea              

______thin stool                              _____straining

______ number of bowel movements per day          is this a change____________________________

______ hemorrhoids                        ____ bloody/black stools          ______night urination    

_____urinary problems                    ____burning on urination           _____ bladder/kidney infection 

_____ bedwetting                           ____ blood in urine                     _____ back pain                        

_______ leg sweling                       ____bone/joint pain                    _____ arm pain                     

______ leg pain                              ____ joint swelling                      _____ varicose veins


Write the approximate year that you incurred any of the following:

______ anemia                           _______arthritis(osteo/rheumatoid)    ______ asthma                

______  blood transfusion         ________ bronchitis                            ______ cancer                          

______ chicken pox                     ______ colitis                                      ______ Crohn's                         

________ diabetes                      ______ diptheria                                 ______ drug reactions                       

______ epilepsy                           ______ fibromyalgia                           _______ gallstones

______ heart attack                    ______ heart disease                          ______ hepatitis             

______ HB pressure                   _______HIV/AIDS                                 ______ hives                              

______ hpoglycemia                   _______ jaundice                                _______ kidney stones               

_______ IBS                                  ______LB pressure                            ______ measles(German/Red)           

_______mental problems             _______ MS                                          _______mumps

______ obesity                              ______ parasites                                 _______ pneumonia          

_______rheumatic fever            _______ skin boils                                  ______ syphilis                        

______ stroke                          _______    TMJ                                          _______tuberculosis                 

_______ulcer                               ______whooping cough                       _______ phlebitis


Personal Physician:___________________________  Telephone:_________________

Date of last physical:_______________________________________ 

Are you allergic to medicines? Which ones?


Are you allergic to foods? Which ones?


Are you allergic to the environment? What?


Please list any medications, prescriptions, or over the counter medicines that you take:


Please list any regular vitamins, minerals, or herbal supplememnts that you take:


Please list any major operations that you have had, and the year:


Please list any major injuries or accidents that you have had and the year

(please include all breaks, sprains and dislocations in this as well):


Please list any major illnesses or hospitalizations that you have had:


Please list any other medical diagnosis that you have had from past or present:



Exercise Information


How often do you exercise weekly? __________________________________________________________________

What form of exercise do you do?____________________________________________________________________

How long do you exercise for?_______________________________________________________________________


I certify that the information provided in this form is true and accuratly reflects my past and present health status.


Signature:__________________________________________      Date:________________