Health Survey - Acupuncture Plus. Your new life of healing starts here!

The purpose of this form is to provide me with as much information as possible about your overall health.

All the information you disclose will be treated with absolute confidentiality. Please be as complete in your answers as possible; each piece of information is important in assembling a comprehensive picture of your health.

Thank you for taking the time to fill out this form.

Carol LeCroy, L.Ac.

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Name and Email Address are required, otherwise please fill out all fields you can answer. *Required Information

*Name

Age

Address (Please include Street, City, State & ZIP)

*E-mail address

Phone (w/area code)

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Please list the 3 major health concerns in order of importance:
Family Medical History
Cancer Heart Trouble Kidney Disease Liver Disease Spinal Problems Diabetes TB Epilepsy Ulcers	Arthritis Mental Disorders High or Low Blood Pressure Allergies Asthma Sinus Problems Alcoholism Drug Addiction Other
Age Parents Died: Mother Father Personal Medical History (include dates of major surgeries, illnesses, diseases, accidents) Contagious Diseases (check if you have ever had one of the following) HIV Aids Hepatitis Venereal Disease Herpes Other Allergies-Known or Suspected (drugs, chemicals, food, animals, seasonal, etc.) Current Medications (include prescriptions, vitamins, herbs, etc.)
Health Habits Tobacco Smoking Yes No Frequency Coffee Yes No Frequency Reg Decaf Tea Yes No Frequency Reg Decaf Alcohol Yes No Frequency Wine Beer Liquor Soft Drinks Yes No Frequency Regular Diet Artificial Sweeteners Yes No Frequency Daily Water Intake: ounces Do you have an adequate energy level? (Y/N) Mark the stress level in your life: (0=No stress, 10=Tremendous stress) What is your job satisfaction? (0=Unsatisfied, 10=Satisfied) How many hours per week do you work? How many hours per week do you have free time? Tendency towards: sadness/depression anger/irritability anxiety/fear mental over-activity Diet - Please describe a typical day's diet:
Breakfast Lunch Dinner Snacks Food Cravings Are you on any type of diet presently? (describe) Do you feel good about your weight? (would you like to gain or lose weight?) Have you recently experienced a significant weight change? Do you know your blood type? Digestion
Indigestion Heartburn Gurgling stomach Bitter taste in mouth Hepatitis/liver trouble Lump in throat Nervous stomach Nausea/Vomiting	Abdominal pain/cramps Gallstones/gallbladder disease Difficulty digesting fatty foods Difficulty swallowing Bloating/gas in lower abdomen Frequent belching Bad breath Ulcers
Bowels
Loose stool Diarrhea Constipation Black stool Intestinal worms Burning anus Blood in stool Hemorrhoids	Anal itch Hard or difficult BM Small amount of stool Undigested food in stool Stool with bad smell Mucus in stool Painful bowel movement Use laxatives
Urination
Frequent Night-time Incontinence Cloudy Urgent Pus Abnormal color Burning/painful	Scanty Profuse Bladder infections Kidney stones/infections Blood in urine Slow or straining to urinate Strong smell
Thirst
Rarely thirsty Always thirsty Thirsty, but do not drink	Always drink cold beverages Always drink hot beverages
Sleep
Difficulty falling asleep Awakened easily Difficulty falling back to sleep	Tired when getting up in the morning Sleep too much How many hours per night do you sleep?
Headaches / Dizziness
Headaches Motion sickness Poor memory Head feels heavy Poor balance	Get dizzy when bending down then standing Vertigo Faint easily Dizzy/lightheaded Migraines
Skin
Dry Oily Nail fungus/infection Rashes/hives Eczema/psoriasis Hives Clammy Pimples Brittle/weak nails Warts Strong body odor Boils	Bruise easily Cuts heal slowly Itching Non-healing sore Premature gray hair Herpes: lips genital zoster (shingles)
Eyes
Wear glasses/contacts Cataracts Spots or lines in vision Poor night vision Sensitive to light Blurry vision Dry Yellow Failing vision History of sties Double vision	Glaucoma Blinking Twitching Swollen eyelids Inflamed eyes Itching Painful Strained Red Tear easily
Ears
Poor hearing Ear aches Excessive wax	Blood/pus discharge Ringing/buzzing
Nose
Runny nose/discharge Nosebleeds Chronic sinus trouble Loss of Smell	Stuffy nose Hay fever Sneeze a lot Snoring
Mouth and Throat
Dry mouth Gum problems Teeth problems Frequent colds Mouth/tongue sores Frequent sore throats TMJ pain	Dry cracked lips Thyroid problems Swollen glands Hiccups Hoarseness Grind teeth
Body Temperature
Easily chilled Feel cold after eating Cold hands and feet	Feel warm or hot Sweat easily Sweat or too warm while sleeping
Respiratory
Shortness of breath Dry cough Bronchitis Tightness in chest Sigh a lot Cough with phlegm	Cough with blood Emphysema Pain with breathing Asthma Chronic cough
Cardiovascular / Circulation
Diagnosed heart problems Bleed easily Heart murmur Broken blood vessels Irregular beat/palpitations Rheumatic fever High cholesterol Purple palms	Varicose veins Chest pain/angina Low blood pressure High blood pressure Swelling of hands/feet/ankles Slow heart rate Numbness in extremities
Pain
Low back Sciatica Upper back Mid back Neck Spine Shoulder Hands or wrists Hips	Knees Feet or ankles Arthritis Muscle weakness Muscle cramps Muscle twitching/spasm Pain in damp weather Nerve Flank Area
For Men Only
Reduced sex drive Prostate problems Difficulty in starting stream of urine Impotence	Pain/burning upon urination Discharge Genital pain Dribbling of urine
For Females Only
Are you or might you be pregnant? (Yes / No / Maybe) Approximate date of conception How often do you have PAP tests? If abnormal, when? How often do you have breast exams? If abnormal, when? Do you have excessive facial or body hair? (Yes / No) Are you experiencing reduced sex drive? (Yes / No)
Menstrual Cycle
Age started: Days of flow: Age begun menopause: Days from the beginning of your period to the start of your next period:
Irregular Scanty flow Dark color flow Constipation Tender breasts Emotional changes Painful Water retention Light color flow	Diarrhea Abdominal bloating Spotting between periods Heavy flow Backache Clotting Tightness in chest Breast lumps
Vaginal Discharge
Yellow White Thick	Clear Bad odor Itching
Menopause Problems (please describe any problems you are experiencing)
Pregnancies
Total number Number of children Number of miscarriages Number of therapeutic abortions Describe any problems with your pregnancies, especially any that resulted in termination.
Gynecological History and Operations (please check and explain where applicable)
Ovaries Yes No Uterus Yes No Fallopian Tubes Yes No Vagina Yes No Breasts Yes No DES exposure Yes No What method of birth control do you now use? What method(s) of birth control have you used in the past?
Please be patient. It may take a moment to process this information.

I received a degree in Traditional Chinese Medicine in 1996 from the Colorado School of TCM in Denver, CO. I am National Board Certified in both Acupuncture and Chinese Herbal Medicine, and licensed as an acupuncturist by the State of Colorado.

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