holly shuman acupuncture
New Patient Questionnaire Mailing address
What is your main complaint?
When did this problem first begin? How often does this bother you?
If there is pain involved, what is the quality of the pain? (Select all that apply)
What makes the problem feel better? (Select all that apply)
To what extent does this problem interfere with your daily activities (work, sleep, sex, etc)?
What kinds of treatment have you tried?
Significant trauma (physical or emotional)?
Surgeries? Please include date(s) of procedure(s)
Allergies (chemical, environmental, food, drugs, etc)
Medications (names and dosages)
Vitamins / Supplements / Herbs
Exercise: Length of workout, type of activity, days per week
Diet: Meals per day, snacks, caffeinated drinks, alcohol per week
PERSONAL HISTORY Please select any conditions or symptoms you have now or have had in the past.
GENERAL: Please select any symptoms you have experienced with the past year
HEAD, EYES, EARS, NOSE AND THROAT
GYNOCOLOGICAL / RPRODUCTIVE (Women Only)
Please list any birth control medications and duration of use:
Please inform me of any other problems you would like to discuss:
To the best of my knowledge, the questions on this form have been accurately answered.
I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform my provider of any changes in my medical status. I also authorize the healthcare staff to perform the necessary healthcare services I may need.
Submit