Innovative Alternatives for Mind and Body
Jennifer Walker, L.Ac., M.Ac.
220A East Ave.
Thomas, WV 26292
(681) 228-9006
PATIENT INFORMATION
PLEASE PRINT
Today’s Date _____________
Name _____________________________ Address ____________________________________________
City____________________________State______ Zip____________
Email address________________________________ Would you like to be included on our email list? ____
Sex: ! M ! F Age ____ Birth date ___________Weight _________Time of birth (if known)_______________
Place of birth___________________________! Single ! Married ! Widowed ! Separated ! Divorced
Occupation _________________________________ Employer __________________________________
Whom may we thank for referring you? ______________________________________________________
PHONE NUMBERS
Home _________________Work_________________ Cell_________________Cell Carrier ___________
Best time and place to reach you __________________________________________________________
IN CASE OF EMERGENCY, CONTACT:
Name ________________________________ Relationship ___________________________
Home Phone __________________________ Work Phone ___________________________
ACCIDENT INFORMATION
Is condition due to an accident? ! Yes ! No
Date of accident______________________
Type of accident: ! Auto ! Work ! Home ! Other ________________________________
Why are you here and what would you like to accomplish with our help?
_____________________________________________________________________________
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Family History
Check illnesses which have occurred in any of your family blood relatives:
! diabetes
! cancer
! bleeding tendency
! kidney disease
! tuberculosis
! heart disease
! stroke
! high blood pressure ! nervous illness
! allergy
! other ______________________________
Your Health History
SYMPTOMS Check (☑ ) symptoms YOU currently have or have had in the past year. You must
check either Yes or No.
GENERAL
1. !Yes !No
2. !Yes !No
3. !Yes !No
4. !Yes !No
5. !Yes !No
6. !Yes !No
7. !Yes !No
8. !Yes !No
9. !Yes !No
10. !Yes !No
11. !Yes !No
12. !Yes !No
13. !Yes !No
14. !Yes !No
15. !Yes !No
16. !Yes !No
17. !Yes !No
18. !Yes !No
19. !Yes !No
20. !Yes !No
21. !Yes !No
22. !Yes !No
23. !Yes !No
Anxiety
Catch colds easily
Chills
Confusion
Depression
Difficult concentration
Dizziness
Fainting
Fatigue
Fever
Forgetfulness
Headache
Indecision
Irritability
Migraine
Nervousness
Numbness
Sensitive to weather changes
Trouble falling asleep
Fall asleep but awaken later
Sweats
Weight gain
Weight loss
Is there one emotion you experience more often
than others (Mark only one):
24. !Yes !No Anger
25. !Yes !No Joy
26. !Yes !No Worry
27. !Yes !No Sadness
28. !Yes !No Fear
Any history of physical, verbal, emotional, or sexual
abuse? Please explain to your comfort level.
__________________________________________
__________________________________________
__________________________________________
Which weather do you find less
tolerable?
! Hot ! Cold ! Neither ! Both
Any thoughts, ideas, fears that you have
often?
________________________________
________________________________
Any recurring dreams?
________________________________
________________________________
Any recurring nightmares?
________________________________
________________________________
EYE, EAR, NOSE, THROAT
29. !Yes !No Allergies / Hay fever
30. !Yes !No Bleeding gums
31. !Yes !No Blurred vision
32. !Yes !No Dry eyes
33. !Yes !No Runny eyes
34. !Yes !No Double vision
35. !Yes !No Difficulty swallowing
36. !Yes !No Earache
37. !Yes !No Ear discharge
38. !Yes !No Sore throat
39. !Yes !No Hoarseness
40. !Yes !No Loss of hearing
41. !Yes !No Nasal congestion
42. !Yes !No Nosebleeds
43. !Yes !No Ringing in ears
44. !Yes !No Sinus problems
45. !Yes !No Vision—Flashes
46. !Yes !No Vision—Halos
RESPIRATORY
47. !Yes !No
48. !Yes !No
49. !Yes !No
50. !Yes !No
Asthma
Cough
Shortness of breath
Wheezing
GENITOURINARY
51. !Yes !No Blood in urine
52. !Yes !No Frequent urination
53. !Yes !No Lack of bladder control
54. !Yes !No Painful urination
How often do you urinate daily?________
GASTROINTESTINAL
55. ! Yes ! No Appetite poor
56. ! Yes ! No Belching
57. ! Yes ! No Bloating
58. ! Yes ! No Bowel changes
59. ! Yes ! No Canker sores inside mouth
60. ! Yes ! No Constipation
61. ! Yes ! No Diarrhea
62. ! Yes ! No Excessive hunger
63. ! Yes ! No Excessive thirst
64. ! Yes ! No Gas (flatulence)
65. ! Yes ! No Hard stools
66. ! Yes ! No Hemorrhoids
67. ! Yes ! No Indigestion
68. ! Yes ! No Nausea
69. ! Yes ! No Reflux
70. ! Yes ! No Rectal bleeding
71. ! Yes ! No Soft stools
72. ! Yes ! No Stomach pain
73. ! Yes ! No Vomiting
74. ! Yes ! No Vomiting blood
How often do you have a bowel movement?
___________________________________
What foods / flavors do you strongly dislike?
___________________________________
What foods / flavors do you crave?
___________________________________
CARDIOVASCULAR
75. !Yes !No Chest pain
76. !Yes !No High blood pressure
77. !Yes !No Irregular heart beat
78. !Yes !No Low blood pressure
79. !Yes !No Poor circulation
80. !Yes !No Rapid Heart Beat
81. !Yes !No Swelling of ankles
82. !Yes !No Varicose veins
MUSCLE/JOINT/BONE
Pain, weakness, numbness in:
83. !Yes !No Arm
84. !Yes !No Back
85. !Yes !No Feet or ankles
86. !Yes !No Hands
87. !Yes !No Hips
88. !Yes !No Knees
89. !Yes !No Legs
90. !Yes !No Neck
91. !Yes !No Fracture easily
92. !Yes !No Strained muscles
93. !Yes !No Sprained ligaments
SKIN
94. !Yes ! No Acne
95. !Yes ! No Bruise easily
96. !Yes ! No Cold sores on lips
97. !Yes ! No Dry skin
98. !Yes ! No Eczema
99. !Yes ! No Flaky scalp
100. !Yes ! No Heavy perspiration
101. !Yes ! No Hives
102. !Yes ! No Itching
103. !Yes ! No Oily skin
104. !Yes ! No Psoriasis
105. !Yes ! No Rash
106. !Yes ! No Rosacea
107. !Yes ! No Scanty perspiration
108. !Yes ! No Scars
109. !Yes ! No Sore that won’t heal
110. !Yes ! No Warts
Are your fingernails:
111. !Yes ! No Soft
112. !Yes ! No Splitting
113. !Yes ! No Ridged, brittle
114. !Yes ! No Discolored
MEN ONLY
115. !Yes !No Breast lump
116. !Yes !No Erection difficulties
117. !Yes !No Lump in testicles
118. !Yes !No Penis discharge
119. !Yes !No Sexual difficulties
120. !Yes !No Sore on penis
Other________________
WOMEN ONLY
121. !Yes !No
122. !Yes !No
123. !Yes !No
124. !Yes !No
125. !Yes !No
126. !Yes !No
127. !Yes !No
128. !Yes !No
Abnormal Pap Smear
Bleeding between periods
Irregular periods
Breast lump
Nipple discharge
Fibrocystic breasts
Extreme menstrual pain
Premenstrual syndrome
129. !Yes !No Hot flashes
130. !Yes !No Fibroid tumors
131. !Yes !No Ovarian cysts
132. !Yes !No Ovarian pain
133. !Yes !No Painful intercourse
134. !Yes !No Sexual difficulties
135. !Yes !No Vaginal discharge
136. !Yes !No Yeast infections
Other________________
Date of last menstrual period ________
Number of pregnancies ____________
Number of children ________
Are you pregnant? ! Yes ! No
Date of last Pap Smear _____________
Have you had a mammogram?
! Yes ! No Date__________
CONDITIONS Check (☑ ) conditions you currently have or have had in the past year. You
must check either Yes or No.
137. !Yes
138. !Yes
139. !Yes
140. !Yes
141. !Yes
142. !Yes
143. !Yes
144. !Yes
145. !Yes
146. !Yes
147. !Yes
148. !Yes
149. !Yes
150. !Yes
151. !Yes
152. !Yes
153. !Yes
154. !Yes
155. !Yes
156. !Yes
157. !Yes
158. !Yes
159. !Yes
160. !Yes
161. !Yes
162. !Yes
163. !Yes
164. !Yes
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No
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No
No
No
AIDS
Alcoholism
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding disorders
Bronchitis
Bulimia
Cancer
Cataracts
Chemical Dependency
Chicken Pox
Diabetes
Emphysema
Epilepsy
Glaucoma
Goiter
Gonorrhea
Gout
Heart Disease
Hepatitis
Hernia
Herpes
High Cholesterol
HIV Positive
Jaundice
165. ! Yes ! No
166. ! Yes ! No
167. ! Yes ! No
168. ! Yes ! No
169. ! Yes ! No
170. ! Yes ! No
171. ! Yes ! No
172. ! Yes ! No
173. ! Yes ! No
174. ! Yes ! No
175. ! Yes ! No
176. ! Yes ! No
177. ! Yes ! No
178. ! Yes ! No
179. ! Yes ! No
180. ! Yes ! No
181. ! Yes ! No
182. ! Yes ! No
183. ! Yes ! No
184. ! Yes ! No
185. ! Yes ! No
186. ! Yes ! No
187. ! Yes ! No
188. ! Yes ! No
189. ! Yes ! No
190. ! Yes ! No
191. ! Yes ! No
Kidney Disease
Liver Disease
Measles
Migraine Headaches
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Nervous Disorder
Osteoporosis
Pacemaker
Pneumonia
Polio
Prostate Problem
Psychiatric Care
Rheumatic Fever
Scarlet Fever
Stroke
Suicide Attempt
Syphilis
Thyroid Problems
Tonsillitis
Tuberculosis
Typhoid Fever
Ulcers
Vaginal Infections
Vein Trouble
EXERCISE
! None
! Moderate
! Daily
! Heavy
WORK ACTIVITY
! Sitting
! Standing
! Light Labor
! Heavy Labor
HABITS
! High Stress Level
! Smoking
! Alcohol
! Coffee or
Caffeine Drinks
! Soda Pop
! DIET soda
! Marijuana
or other drugs
Reason __________
_________________
Packs per Day _____
Drinks per Week ___
Amount/Day ______
Amount/Day ______
Amount/Day ______
Amount/Week _____
Injuries/Surgeries you have had:
Description
Year
Falls
______________________________________________________________
Head Injuries
______________________________________________________________
Broken Bones
______________________________________________________________
Dislocations
______________________________________________________________
Surgeries
______________________________________________________________
! Yes ! No Have you ever had any allergic reactions to shellfish?
! Yes ! No Are you allergic to Novocain or Xylocaine?
! Yes ! No Do you have allergic reactions to latex?
ALLERGIES Please list any allergies known to you.
(foods, molds, etc.)______________________________________________________________________
_____________________________________________________________________________
Please list below your current medications and any supplements you take with the dosages and
frequency if known. If you take none please indicate that in each column.
PRESCRIPTION MEDICATIONS
VITAMINS/HERBS/MINERALS
___________________________________
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Select the statement that best describes your dietary habits.
How often do you eat breakfast?
! Never
! Always
! Occasionally
! Most of the time
Which statement best describes your daily eating routine?
! I try to eat the traditional three meals daily.
! I try to eat several small meals and only seldom a large meal.
! I snack often and seldom eat a full meal.
! I eat only one to two meals a day.
! My meal schedule is highly irregular, alternating between one meal a day with several snacks
to two or three large meals a day.
Which statement best describes your preference for eating dessert?
! I almost always have desserts after my meals.
! I often, but not always, have desserts after meals.
! I occasionally have desserts after meals.
! I seldom have desserts after meals.
! I avoid having dessert.
What best describes how your eating patterns have changed, as you get older?
! I continue to eat about the same as before.
! I have increased my food intake.
! I have decreased my food intake.
! I eat the same total amount, but smaller and more frequent meals.
! I am on a medically prescribed diet.
How often do you eat at "fast food" restaurants?
! Most of the time.
! About once a day.
! Three to four times a week.
! Once or twice a week.
! Hardly ever.
Answer True or False to the following statements:
T F
! ! I often snack between meals.
! ! I routinely try new weight-loss diets.
! ! I eat whatever is around or available.
! ! I often overeat at dinner.
! ! I take vitamin and mineral supplements for adequate nutrition.
! ! I eat a wide variety of foods.
! ! I eat only “fresh" foods.
! ! I consciously limit the calories I eat.
! ! I seldom eat desserts.
! ! I eat only certified organically grown foods.
! ! I have a kosher or equivalent type of diet.
! ! I am on a medically supervised diet schedule.
! ! I am a vegetarian or vegan (please circle).
! ! I am mindful of what I eat and try to be careful.
Which of the following best describes your red (beef, pork, lamb, and veal) meat-eating habits?
! I don't eat red meat.
! I eat red meat fewer than four times each week
! I eat red meat between seven and four times each week.
! I eat red meat more than seven times each week.
Which of the following best describes your egg-eating habits?
! I don't eat eggs.
! I eat fewer than four eggs each week.
! I eat between seven and four eggs each week.
! I eat more than seven eggs a week.
Indicate your use of dairy products by placing a check in the appropriate blanks:
Average 3 or
Average 1 or
Eat/drink it
more servings daily
2 servings daily
occasionally
Butter
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Margarine
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Whole milk
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Low-fat milk
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Hard cheese
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Other cheeses
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Cream
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Ice cream
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How often do you have the following items for snacks?
Over 4
3-4 times
1-2 times
times a day
a day
a day
! Soda pop
! Diet soda
! Candy
! Cookies
! Cakes
! Pies
! Potato Chips
! Pretzels
! Ice cream
! Snack cheese
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Occasionally
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Never
eat/drink it
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Seldom
or never
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Which statement best describes the way you use table salt?
! I usually add salt before tasting my food.
! I occasionally add salt to my food.
! I usually add salt because my food is never salty enough.
! I seldom have to add salt to my food.
! I make it a rule never to add or cook with salt.
How much smoked or cured meats such as bacon, ham, or other prepared or packaged meat
products do you eat?
! I eat these products at least once a day.
! I eat products such as these three to five times a week.
! I eat products such as these at least once a week.
! I eat products such as these occasionally.
! I don't eat prepared, packaged meat products.
How much coffee or tea do you drink each day?
Coffee
BlackTea
GreenTea
HerbalTea
10 or
more cups
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7-10 cups
5-6 cups
3-4 cups
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1-2 cups
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less than
1 cup
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None
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On the average, how much alcohol do you drink?
Beer
Ale
Wine
Whiskeys
Gin
Vodka
Bourbon
Cocktails
Liqueurs
Cordials
10+ drinks 9-10
7-8
5-6
3-4
1-2
<1
per day per day per day per day per day per day per day
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Which statement best describes your intake of fats?
! I don't worry about fat intake.
! I limit my intake of unsaturated fats to 10 percent or less of my total diet.
! I eat fats only occasionally, and they are not a regular part of my diet.
! I eat no animal fats.
<1
per day
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don’t
drink
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Please list your major health concerns in detail:
Problem#1_______________________________________________________
_____________________________________________________________________________
What makes it worse (certain weather, activity, rest, certain foods, etc.)?____________________
_____________________________________________________________________________
What makes it feel better?________________________________________________________
When does it bother you most (time of day, season, before periods, etc.)? __________________
If your problem causes you pain, describe it as closely as possible:
___ sore, bruised
___ aching ___ cramping, drawing ___ sharp, stabbing ___ burning
Choose ONE: ___ steady ___ throbbing ___ intermittent
Please mark on the 1-10 scale your overall level of pain at present.
MY PAIN IS:
No pain
Unbearable
__________________________________________
0
1
2
3
4
5
6
7
8
9
10
Problem #2______________________________________________________
_____________________________________________________________________________
What makes it worse?___________________________________________________________
What makes it feel better? _______________________________________________________
When does it bother you most?____________________________________________________
If your problem causes you pain, describe it as closely as possible:
___ sore, bruised ___ aching ___ cramping, drawing ___ sharp, stabbing ___ burning
Choose ONE: ___ steady ___ throbbing ___ intermittent
Please mark on the 1-10 scale your overall level of pain at present.
MY PAIN IS:
No pain
Unbearable
__________________________________________
0
1
2
3
4
5
6
7
8
9
10
Problem #3______________________________________________________
_____________________________________________________________________________
What makes it worse?___________________________________________________________
What makes it feel better?________________________________________________________
When does it bother you most?____________________________________________________
If your problem causes you pain, describe it as closely as possible:
___ sore, bruised ___ aching ___ cramping, drawing ___ sharp, stabbing ___ burning
Choose ONE: ___ steady ___ throbbing ___ intermittent
Please mark on the 1-10 scale your overall level of pain at present.
MY PAIN IS:
No pain
Unbearable
__________________________________________
0
1
2
3
4
5
6
7
8
9
10
Please indicate the appropriate location of your pain and the symbol that best describes the
discomfort you are presently experiencing.
!
!
Sharp and stabbing = + + + +
Dull and achy = v v v v
Pins and needles = o o o o
Numbness = / / / /