Online Health Questionaire - Vital Energy Acupuncture Clinic

Your Information

First Name

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Last Name

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E-mail

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Date of Birth

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Address

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City

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Province

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Postal Code

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Home Phone

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Work Phone

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Mobile Phone

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Married?

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Referred By?

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Occupation

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Physician Information

First Name

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Last Name

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Physicians Phone

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Address

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City

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Province

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Postal Code

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Emergency Contact

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Last Name

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Phone

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Medical / Physical Questions

Please describe your Main Complaint (symptoms, duration, prior treatments, etc.)

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What makes your condition(s) better? (movement, sleep, heat, cold, eating, meditation, etc.)

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What makes your condition(s) worse? (stress, rainy days, foods, hunger, tired, heat, etc.)

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Allergies and Environmental Exposures (food, plant, chemical, metal, drugs, etc.)

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Significant Trauma (physical or emotional)

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Surgeries (date/s)

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Current Medications (dosages and names of product)

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Exercise (Days/week) - Type of Exercise - Duration of workout

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Diet (Meals/day) - Time of meals - Snacks (per day) - Alcohol (drinks/week) - Caffeine (drinks/day)

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What Vitamins, Supplements, or Herbs have you taken? What results?

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Health Questionaire

Your Information

Physician Information

Emergency Contact

Medical / Physical Questions

Detailed History

Please Check if you have had any of these items listed below in THE LAST YEAR