PERSONAL HISTORY

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PERSONAL HISTORY Name ____________________________
__________ Address_____________________________
_________________ City ___________________________
_____________ State/Prov ___________Zip/Postal
Code____________________ Home Phone
_________________________________ Birth Date
______________Age _____ Sex M
F Social Security ______________________________
Circle one Married Single Widowed
Divorced Separated Business Employer
____________________________ Type of
Work_________________________________________ Busi
ness Phone _______________________________ Name
of Spouse_______________________________________ N
ame and Ages of Children__________________________
_________________________________________________
Referred to This Office By ______________________
Name and Number of Emergency Contact____________
_______ E-Mail address ___________________________
__________________________________________________
________ Insurance Plan Name or Program
Name______________________________________________
____________________ Insured Name, DOB and
ID_______________________________________________
___________________________ ______________________
__________________________________________________
_______________
CURRENT HEALTH
CONDITION Main Complaint__________________________
__________________________________________________
_________ Doctors Seen For This Condition
__________________________________________________
_____________________ Type of Treatment
_____________________________
Results___________________________________________
___ When Did This Condition Begin?________________
__ Date of Accident _____________________________
__________ Is This Condition Job Related
Auto Accident Home Injury Fall
Other_____________________________ Brief
Description of Accident___________________________
________________________________________________ _
__________________________________________________
_______________________________________________ Dr
ugs You Now Take Pain Killers/Muscle Relaxers
Nerve Pills Blood Pressure Medicine
Insulin
Other_____________________________________________
____________________________ Do You Suffer From
Any Condition Other Than That Which You Are Now
Consulting US?____________________________ _______
__________________________________________________
_________________________________________ _______
__________________________________________________
_______________________________

PAST HEALTH HISTORY Major Surgery/Operation
Appendectomy Tonsillectomy Gall
Bladder Hernia Back Surgery
Broken
Bones Other _______________________________
_____________________ Hospitalization (Other Than
Above) __________________________________________
___________________________ Previous Acupuncture
Care Yes No
Doctors Name ____________________________________
__ Condition for Acupuncture _____________________
__ Acupuncture Results _______________________
__________ _