Patient Name: Date:

Are you allergic to any medications? No Yes     If so, please list:

Past Medical History

Diabetes  Yes No Osteoporosis  Yes No Blood Clots  Yes No Chest Pain/Angina  Yes No
Asthma/COPD  Yes No Peripheral Vascular Disease  Yes No High Blood Pressure  Yes No Stroke/CVA/TIA  Yes No
Tuberculosis  Yes No Heart Disease  Yes No Seizures  Yes No Depression  Yes No
Heart Attack  Yes No HIV/AIDS  Yes No Congestive Heart Failure  Yes No High Cholesterol  Yes No
Hepatitis  Yes No Thyroid Disease  Yes No Pacemaker  Yes No Stomach Ulcer  Yes No
Headaches  Yes No Kidney Stones  Yes No Heart Palpitations  Yes No Kidney Disease  Yes No
Arthritis  Yes No Cancer  Yes No Heart Surgery  Yes No

Other health conditions not mentioned above: 

Current Medications: 

ROS Please check all CURRENT positive findings
Constitutional   Weight Loss    Fevers    Chills    Poor Appetite    Fatigue    Weight Gain    Insomnia    Night Sweats 
Eyes   Blurry Vision    Eye Pain    Eye Discharge    Eye Redness    Decrease in Vision    Dry Eyes    Double Vision 
ENT   Sore Throat    Hoarseness    Ear Pain    Hearing Loss    Ear Discharge    Nose Bleeds    Tinnitus    Sinus Problems 
Cardiovascular   Chest Pain    Palpitations    Rapid Heart Rate    Heart Murmur    Poor Circulation    Swelling in the legs or feet 
Respiratory   Shortness of Breath    Chronic Cough    Coughing Up Blood    History of Tuberculosis    Excess sputum production 
Gastrointestinal   Nausea    Vomiting    Diarrhea    Constipation    Blood In the Stool    Frequent Heartburn    Trouble Swallowing 
Genitourinary   Increased Urinary Frequency    Blood in Urine    Incontinence    Constipation    Painful Urination    Urinary Retention    Frequent UTIs 
Skin   Rash    Hives    Hair Loss    Skin sores or ulcers    Itching    Skin Thickening    Nail Changes    Mole Changes 
Musculoskeletal   Joint Pain    Muscle Aches    Frequent Leg Cramps    Muscle Weakness    Bone Pain    Joint Swelling    Back Pain 
Psychiatric   Anxiety    Depression    Alcohol or Drug Dependence    Suicidal Thoughts    Panic Attacks    Use of anti-depressants 
Endocrine   Goiter    Heat Intolerance    Cold Intolerance    Increased Thirst    Change in Skin Pigment    Excess Sweating 
Neurological   Seizures    Tremors    Migraines    Numbness    Dizziness/Vertigo    Loss of Balance    Slurred Speech    Stroke 
Hem/Lymphatic   Low blood count    Easy bruising    Swollen lymph nodes    Transfusions    Prolonged Bleeding    Blood Clots 
Allergic/Immun   Allergic Reactions    Hay fever    Frequent infections    Hepatitis    HIV Positive    Positive tuberculin skin test 

Social History

Martial Status:    Occupation(or most recent job held): 

 Non-Smoker(never smoked)    Ex-Smoker   Current Smoker   How many packs per day? 

Alcohol Consumption:  Never   Occasional   Frequent 

Family History: (Please list any known medical problems)




Your Children(if any):

Additional Information:

How did you hear about A-A-Acupuncture?: