Health History Questionnaire 2021

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Health History Questionnaire

This questionnaire is to help me provide you with a complete evaluation. Please take some time to consider the questions. All answers will be confidential. Thank you.

Date:

Name *

Phone *

Address

Email *

Please enter your email, so we can follow up with you.

Date of Birth

Emergency Contact:

Contact Number

What are your current health concerns?

What are your Health Goals?

Have you ever experienced any accidents or surgeries?

Have you ever experienced physical/ mental/ emotional trauma?

Do you have any medical conditions?/ if so for how long?

Are you taking any medication or supplements?

Are there any major illness's in your immediate family?

Do you know about your own birth?

What are your support networks and how do you nourish and support yourself?

Please tick if you have experienced within the last 6 months:

Head/Senses

Eye Problems
Teeth Problems
TMJ
Sinus/allergy
Swollen glands
Ear Problems

Respiratory/Cardiovascular

Chest pain
Breathing problems
Cough
Palpitations
High or low BP

Digestion

Diarrhoea
Constipation
Bloating
Nausea
Food intolerances

General

Poor sleep
Fatigue
Cold hands & dizziness
Depression/anxiety

Musculo-skeleta

Neck/shoulder pain
Back pain
Joint pain
Muscle pain
Tendonitis
Bursitis

Gynae/Urinary

Urination problems
Irregular periods
Painful periods
No of pregnancies
No of live births
Contraceptive pill

email : info@stillpointacupuncture.co.nz links

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