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Last name:_________________________

Confidential Health History Questionnaire
Full Name: ___________________________________________ Initial Visit Date: __________ (Circle): single partner living together married divorced widow Miss Ms. Mrs. Mr. Date of Birth: _______/_______/_______ Age: _______ SSN: _______-_______-______ Home Address: _________________________________________________________________ Home phone: ( ) Occupation: ____________________________ Employer: ______________________________ Email Address: _________________________________________________________________ How did you hear about our office? (circle) Friend Patient Name:_____________________ Physician referral Name:__________________ Website Internet Newspaper Emergency contact: _____________________ phone #: ________________________________
Primary Care Physician: ______________________________ phone #:___________________
OBGYN: ___________________________________________ phone #:___________________
Primary Insurance Carrier: __________________________ ID#:______________________
Name on card: _________________________ relationship to patient: ______________________
Secondary Insurance Carrier: _________________________ ID#:______________________
Name on card: _________________________ relationship to patient: ______________________ LIST AREAS OF PAIN AND OTHER CONDITIONS TO BE TREATED:
1. ____________________________________________________________________________
How long have you had this: _______ days/weeks/months/years? Is this a flare up? Yes/No How frequently do you experience this condition: constant/daily/monthly/seasonally What is the Intensity of your Discomfort: 1 – 10 (10 being most severe): _____
Is your pain or discomfort:
( ) Sharp ( ) Burning ( ) Aching ( ) Cramping ( ) Tight
Have you had an ( ) X-ray ( ) MRI ( ) CAT scan ( )other: ______________________ Treating Physicians (circle): MD PT ORTHO CHIRO other:_____________________

2.
____________________________________________________________________________
How long have you had this: _______ days/weeks/months/years. Is this a flare up? Yes/No How frequently do you experience this condition: constant/daily/monthly/seasonally What is the Intensity of your Discomfort: 1 – 10 (10 being most severe): _____
Is your pain or discomfort:
( ) Sharp ( ) Burning ( ) Aching ( ) Cramping ( ) Tight
Have you had an ( ) X-ray ( ) MRI ( ) CAT scan ( )other: ______________________
Treating Physicians (circle): MD PT ORTHO CHIRO other:_____________________
Are any of the above conditions due to an automobile accident? YES/NO

Is there an active personal injury case? YES/NO
Ocean Acupuncture & Herbal Medicine, LLC 102 East Bay Avenue, Suite C, Manahawkin, NJ 08050 phone: (609) 978-1428 fax: (609) 978-1610 Confidential Health History Questionnaire
Pain Management: CHECK ALL areas where you experience pain and discomfort:

HEAD ( ) temples ( ) forehead ( ) sinuses
( ) low back ( ) abdomen ( ) intestines ( ) hips
Medical History:

Month and year of your last Physical: _____/_____ Bloodwork: _____/_____
Month and year of your last Colonoscopy: _____/_____ ____ Have not had one

CHECK any condition YOU have had or currently have.

( ) Addiction: ___________ ( ) Ebstein Barr Virus, EBV ( ) Meningitis, viral/bacterial
( ) Allergies
( ) Headaches: tension / cluster ( ) Osteoporosis ( ) Bursitis: _____________ ( ) Heart Disease: heart attack ( ) Pneumonia ( ) Cancer: _____________ ( ) Hepatitis A/B/C, chronic ( ) Polio ( ) Cancer: _____________ ( ) High Blood Pressure ( ) High Cholesterol: _____ ( ) Reflux / Ulcers FAMILY HISTORY: Check if your family members have had the conditions below:
Heart Attack/Stroke Cancer High Blood Pressure High Cholesterol Depression _____________________________________________________________________________________________________________________________ ___________________________________________________________________________________________
Please list ALL known ALLERGIES:

1. ________________________________________
2. ________________________________________ Ocean Acupuncture & Herbal Medicine, LLC 102 East Bay Avenue, Suite C, Manahawkin, NJ 08050 phone: (609) 978-1428 fax: (609) 978-1610 Confidential Health History Questionnaire
Medications & Supplements Dosage
What Condition _ How Long
2. __________________________ __________ 3. __________________________ __________ 4. __________________________ __________
Use back of paper if you need extra room. ____ See back of paper (check if needed)

Please list your surgeries and/or hospitalizations Year
For what condition___
1.________________________________________ 2. _______________________________________ 3. _______________________________________ 4. _______________________________________ WOMEN ONLY: MENSTRUAL AND FERTILITY INFORMATION:

Age of first menstruation: _________________
Days of Cycle (period to period): # ________ Average number of days you bleed: _________ Pregnancies: _____ Miscarriages: _____ Fertility specialist:_______________________ CHECK if you have or had any of these conditions?
( ) pain between cycles ( ) endometriosis ( ) yeast infections ( ) fibrocystic breasts ( ) ovarian cysts ( ) spotting between cycles ( ) hysterectomy: partial or full ( ) Menopausal changes Mark a “B” if symptom occurs Before your cycle begins, “D” if during, and “A” if after.
( ) breast tenderness ( ) heavy bleeding ( ) clots: small/large ( ) abdominal pain
MEN ONLY: Please check if you have any of the following conditions:

( ) Low testosterone ( ) Erectile dysfunction ( ) STD
BRING IN ALL TESTS, REPORTS AND BLOODWORK TO YOUR FIRST VISIT.
Patient/Guardian Signature: ___________________Print Name: ________________

Ocean Acupuncture & Herbal Medicine, LLC 102 East Bay Avenue, Suite C, Manahawkin, NJ 08050 phone: (609) 978-1428 fax: (609) 978-1610

Source: http://www.oceanacupuncture.net/Portals/18/Docs/ROF_D1_HEALTH_HX_QUESTIONAIRE.pdf

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