Steve Sterling, LAc, ACN, Dipl of OM

Board Licensed / Nationally Certified Acupuncturist & Chinese Herbalist

This is a CONFIDENTIAL questionnaire to help determine the best treatment plan for you
Name__________________________________________________________ Date___________________________

Home Address_____________________________________________ City__________________________________

State________ Zip________________ Home Phone__________________________ Work____________________

Occupation_____________________________ Person Responsible for your account____________________________

Emergency Contact_______________________________________ Phone________________________________

Who can we thank for referring you?___________________________________________________________________

Sex___ M___F Height__________ Weight__________ Birth date______________ Age________

Marital Status □ Married □ Single □ Divorced □ Widowed Number of Children____________________________

Previous Acupuncture? □ yes □ no When?___________________ With Whom____________________________

Please indicate any significant illnesses you or a blood relative (grandparent, parent, or sibling) have had
Illness You Relative When? Illness You Relative When?
Cancer □ □ ______ Diabetes □ □ ______
Hepatitis □ □ ______ Heart Disease □ □ ______
High blood pressure □ □ ______ Seizures □ □ ______
Rheumatic Fever □ □ ______ Emotional disorders □ □ ______
Infectious Disease □ □ ______ Tuberculosis □ □ ______

Sexually Transmitted disease: □ gonorrhea □ syphilis □ HIV □ HPV □ chlamydia □ herpes Date: ______

Please indicate the use and frequency of the following:

Yes No Amount Yes No Amount Yes No Amount
Coffe/black tea □ □ ________ Tobacco □ □ _________ Water intake □ □ ________
Recreational drugs □ □ ________ Alcohol □ □ _________ Soda Pop □ □ ________

Please check the box if any of the following statements are true:
I have known allergies □ I am taking Coumadin / Warfarin □
I have a pacemaker □ I am taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs) □

List any medications and supplements you are currently taking: (continue on the back if needed)
Medicine Dosage Reason How Prescribed by Date last
Long checkup
 For Women

Age of 1st period (menarche)________ Are you pregnant? □Yes □ No # of pregnancies__________________

Age of last period (menopause)______ # of live births______ # of abortions______ # of miscarriages______________
Number of days between periods_____ Date of last gynecological exam____________ Pap smear________________
Number of days of flow____________ Mammogram_______________ Bone density scan_______________________
Color of flow____________________ Results__________________________________________________________
Clots? □ Yes □ No Color_________ _________________________________________________________
Average number of pads you use per day: 1st day_______ 2nd day_______ 3rd day_______ 4th day_______ +days______
Have you been diagnosed with: □ Fibroids □ Fibrocystic Breasts □ Endometriosis □ Ovarian Cysts □ PID Other_______
Location of Pain: □ Lower abdomen □ Lower back □ Thighs □ Other_________________________
Nature of pain: (please indicate before, during or after menses) Other symptoms related to menses
Cramping_____________ Stabbing_____________ □ Discharge □ Vaginal dryness □ Headache
Burning_______________ Aching______________ □ Nausea □ Constipation □ Diarrhea
Dull__________________ Bloating_____________ □ Swollen breasts □ Mood swings □ Ravenous appetite
Consistent_____________ Intermittent___________ □ Poor Appetite □ Hot flashes □ Night sweats
Bearing down sensation__________________________ □ Increased libido □ Decreased libido □ Insomnia

For Men

Date of last prostate check up_____________ PSA results___________ Manual prostate exam results___________
Lab results________________________________________________________________________________________
Frequency of urination: daytime________ night time________ Color of urine: □ clear □ murky odor:___________
Symptoms related to prostate
□ Prostate problems □ Delayed stream □ Dribbling □ Incontinence □ Retention of urine
□ Rectal dysfunction □ Increased libido □ Decreased libido □ Premature ejaculation □ Impotence
□ Back pain □ Groin pain □ Testicular pain Other_________________________________

Symptom Survey (For Everyone)

The following is a list of symptoms that you may or may not ever experience. Please indicate as follows:
no mark ( ) = never experience check mark (√) = sometimes experience Plus sign (+) = frequently experience
___ lack of appetite ___ abdominal pain ___ eye problems ___ fatigue
___ excessive appetite ___ chest pain ___ jaundice (yellowish ___ edema
___ loose stool or diarrhea ___ sciatic pain eyes or skin) ___ blood in stool
___ digestive problems, ___ headaches ___ difficulty digesting ___ black tarry stool
indigestion ___ pain pr coldness in the oily foods ___ easily bruised
___ vomiting genital area ___ gall stones ___ difficult stop bleeding
___ belching, burping ___ light colored stool ___ asthma
___ heartburn/ reflux ___ cough ___ soft or brittle nails ___ tendency to catch
___ feeling the retention of ___ shortness of breath ___ easily angered or agitated colds easily
food in the stomach ___ decreased sense of ___ difficulty in making ___ intolerance to
___ tendency to become smell plans or decisions weather changes
obsessive in work ___ nasal problems ___ spasms or twitching ___ allergies
relationships ___ skin problems of muscles ___ hay fever
___ feeling of ___ dizziness
___ insomnia, difficulty claustrophobia ___ low back pain ___ tendency faint easily
sleeping ___ bronchitis ___ knee problems ___ high cholesterol levels
___ heart palpitations ___ colitis or ___ hearing impairment ___ sudden weight loss
___ cold hands and feet diverticultis ___ ear ringing
___ nightmares ___ constipation ___ kidney stones
___ mentally restless ___ hemorrhoids ___ decreased sex drive
___ laughing for no ___ recent use of antibiotics ___ hair loss
apparent reason ___ urinary problems
___ angina pains
What are the main health problems for which Clinical Notes
you are seeking treatment?
________________________________________
________________________________________

Which other forms of treatment have you

sought? _________________________________
________________________________________
________________________________________

List any other health problems you now have

________________________________________
________________________________________
________________________________________
________________________________________

List any allergies, food sensitivities or food craving

that you have. ____________________________
________________________________________
________________________________________
________________________________________

List any accidents, surgeries, or hospitalizations

(include date). ____________________________
________________________________________
________________________________________
________________________________________
________________________________________

Lab Results: (please include copies)___________

________________________________________
________________________________________
How do you FEEL about the following areas of your life? Please check the appropriate boxes and indicate any
problems you may be experiencing.

Great Good Fair Poor Bad Your Comments

Significant
Other □ □ □ □ □ ________________________________________________
Family □ □ □ □ □
________________________________________________
Diet □ □ □ □ □
Sex □ □ □ □ □ ________________________________________________
Self □ □ □ □ □
________________________________________________
Work □ □ □ □ □
Exercise □ □ □ □ □ ________________________________________________
Spirituality □ □ □ □ □
________________________________________________
 Patient Pain Drawing

Patient Name___________________________________________ Date:__________________

Mark the areas on your body where you feel the described sensations. Use the appropriate symbol. Include all affected
areas.

Ache Numbness Pins & needles Burning Stabbing

△△△△△ ====== ○○○○○○ xxxxxx ///////

Back Pain in arms compared to neck Front

□ worse than
□ same as
□ less than

Pain in leg(s) compared to neck

□ worse than
□ same as
□ less than