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                                 Fan Acupuncture Clinic
                    Acupuncture & Chinese Herbal Medicine
     90 Madison Street, Suite 402, Denver, CO 80206 Phone: (720)244-3035

Patient Name ______________    Age _____    Male / Female ____

Date of Birth ______/______/______  Height _________    Weight ______  Marital Status _____

Occupation __________Referred By __________    E-mail________________________

Phone (H) (_______) _________ - ________          Phone (Cell) (______) _______-________

Address__________________________________________________________________________

City _________________   State________   Zip _________  Driver’s License No.___________

Emergency Information (Please indicate who to notify in case of emergency)

Name ________________________ Relationship ____________________________

Phone (H) (____) _____-_____Phone (W) (___ ) ______-______Phone (C) (____) _____-_____

Chief Complaint(s) Please indicate how long you’ve had the condition(s).





What kinds of treatments have you received?


List any Hospitalizations & Surgeries (include Date and Place)



List medications being taken (include dosage)



Family History (please include the relationship)
[] Migraines ___________    [] Stroke __________     [] Heart Disease __________
[] High Blood Pressure________     []Allergies_________     [] Mental Illness ______
[] Asthma ___________     [] Gall Stones_________         [] Arthritis ___________
[] Cancer____________     [] Diabetes___________     [] Thyroid Disease________
[] Glaucoma_________      [] Epilepsy___________

Are you allergic to any of the following? If yes, please specify)
[] Medicine     [] Food     [] Herbs     [] Others

Do you have or are you any of the following?
[] Pacemaker     [] Electric Implants     [] Metal Implants     [] Severe Bleeding Disorders
[] Pregnant      [] HIV Positive     [] Hepatitis A/B/C

Life style:
[] Exercise     [] Sedentary    [] Eat three meals every day   [] Eat at regular time every day
[] Tea          [] Coffee          []Softt drink         [] Alcohol
[] Cigarettes    [] Drug 

                                                       Confidential Patient Health History

    Name: ______________________________________ Date: ___/___/________

Please check if you have had (in the past three months):
General
[]Anemia                    [] Poor Appetite                   [] Tremors
[] Fatigue                    [] Localized Weakness                  [] Poor Balance
[] Fever                    [] Bleed or Bruise Easily                  [] Cravings
[] Weight Loss             [] Peculiar Tastes or Smells               [] Weight Gain
[] Sweats                [] Strong Thirst (hot or cold drinks)        [] Alcoholism
[] Chills                         [] Energy Drop                     [] Tetanus Shot
[] Drug Addiction        [] Poor Sleep Habits             [] Frequent cold/flu

Skin and Hair
[] Rashes                 [] Open sore            [] Recent moles                         [] Itching
[] Acne               []Loss of Hair                [] Dandruff               [] Corns
[] Hives              [] Change in hair/skin texturebsp;    [] Warts             [] Nail Problems
[] Ulcerations               [] Psoriasis         [] Dry skinPsoriasis             [] Eczema

Head, Eyes, Ears, Nose and Throat
[] Dizziness/Vertigo                [] Concussions             []Migraines   Psoriasis      [] Poor Vision
[] Eye Strain                  [] Eye Pain                    [] Cataracts                   [] Night Blindness
[] Color Blindness                  [] Ringing in ears         [] Blurry Vision       [] Earaches
[] Sinus Problems             [] Poor Hearing         [] Spots in front of eyes    [] Grinding Teeth
[] Nose Bleeds                 [] Recurrent Sore Throats           [] Nasal Congestion
[] Hoarseness       Psoriasis   [] Facial Pain                  [] Headaches

Cardiovascular
[] High Blood Pressure        [] Myocarditis        [] Coronary Heart Disease      [] Low Blood Pressure
[] Pneumatic Heart Disease       [] Difficulty in Breathing  [] Palpitations       [] Chest Pain
[] Hardening of Arteries         [] Irregular Heartbeat      [] Varicose Veins          [] Phlebitis
[] Mitral Stenosis          [] Swelling of Hands/Feet     [] Blood Clots
[] Mitral Prolapse                           [] Fainting                       [] Cold hands/feet

Respiratory
[] Cough                    [] Coughing Blood          [] Pain w/ deep breath            [] Bronchitis
[] Pneumonia            []Production of phlegm                 [] Difficulty breathing lying down              [] Asthma                                      [] Pleurisy                       [] Emphysema

Gastrointestinal
[] Nausea              [] Constipation                 [] Diarrhea             [] Vomiting
[] Gas             [] Belching                       [] Bad Breath          [] Blood in Stools
[] Black Stools            [] Abdominal Pain or Cramps             [] Rectal Pain
[] Hemorrhoids         ; [] Indigestion            [] Chronic Laxative Use       [] Acid Reflux
[] Ulcer              [] Colitis

Genitourinary
[] Bed Wetting            [] Blood in Urine              [] Frequent Urination       
[] Kidney Infections / Stones           [] Painful Urination               [] Bladder Infections           
[] Genital Herpes       [] Venereal Disease            & [] Cystitis             [] Incontinence

Pregnancy and Gynecology
[] Number of Pregnancies           []Age at 1st Menstruation            [] Unusual Character (heavy/light)
[] Number of Abortions ___ Time between Menstruation            [] Vaginal Sores
[] Number of Births ___ Duration of Menstruation          [] Vaginal Discharge
[] Number of Miscarriages ___ First Date of Last Menstruation                          [] Breast Lumps
[] Use of Birth Control                [] Irregular Periods           [] Uterine Fibroids
[] Hot Flash/Night Sweats           [] Frequent changes in emotion                       [] Osteoporosis

Fertility Information
# of IVF procedures____________# of IUI procedures__________________________________

Has a physician diagnosed a difficulty with fertility due to:
[] Female Factor?                          [] Male Factor?                   [] Unexplained

Musculoskeletal
[] Neck Pain              [] Muscle Pain              [] Knee Pain
[] Back Pain              [] Muscle Weakness                  [] Foot/Ankle Pain
[] Hand/Wrist Pain          [] Shoulder Pain         [] Hip Pain

Please indicate on the figures below the areas of the body you experience your pain:
[] dull/achy                  [] sharp/stabbing                [] burning
[] tingling                         [] numbness          [] electrical

Neuropsychological
[] Seizures               [] Dizziness           [] Loss of Balance         [] Areas of Numbness
[] Lack of Coordination        [] Poor Memory           [] Concussion           [] Depression
[] Anxiety           [] Bad Temper             [] Easily susceptible to stress             
[] ADD               [] Difficulty Concentrating

Infection
[] Measles             [] Mumps           [] Whopping Cough         [] Rheumatic Fever 
[] Tuberculosis          [] Typhoid Fever         [] Malaria        [] Chicken Pox               
[] Scarlet Fever                         [] Small Pox