Pindoctor, LLC Health History Form
Name
*
Address
*
City, State, ZIP
*
Phone Number(s)
*
Email
*
Emergency Contact and Phone Number
*
Occupation
Age
*
Height
*
Weight
*
Have you had acupuncture before?
*
Yes
No
Have you had massage before?
*
Yes
No
How did you hear about the Pindoctor?
*
Please Select
Internet
From a Current Client
Linden Hills Booklet
Word of Mouth
Other
PRIMARY HEALTH CONCERN (Onset, duration, pain location, etc.)
*
Have you tried other therapies? What has been beneficial?
*
Are you taking any medications, herbs or supplements for this issue?
*
SECONDARY HEALTH CONCERN (Onset, duration, pain location, etc.)
Have you tried other therapies? What has been beneficial?
Are you taking any medications, herbs or supplements for this issue?
Any surgeries, hospitalizations or other traumatic events?
OTHER HEALTH CONCERNS (See below also)
How are your eyes?
*
No Problems
Blurry
Red
Watery
Dry
Macular Degen. (Dry)
Macular Degen. (Wet)
Glaucoma
How are your ears?
*
No Problems
Hearing Loss
Ringing
Excess Wax
How is your nose/sinus?
*
No Problems
Chronic Infections
Allergies
Colored mucus
Clear mucus
Nosebleeds
How's your mouth & teeth?
*
No Problems
Bleeding Gums
Gingivitis
Canker Sores
Tongue Ulcers
Bad Breath
Do you have amalgam (sliver) fillings?
*
Yes
No
Had Them Removed
How is your sleep?
*
Restful
Hard to Fall Asleep
Wake in the Night
Nightsweats
Dreams
Nightmares
Sleepwalk
What mood best describes how you feel today?
*
Happy
Angry
Sad
Worrisome
Fearful/Stuck
Creative
Energized
Disorganized
If you smoke, how much?
Any additional respiratory (heart/lung) issues?
Do you have a pacemaker?
*
Yes
No
Do you have a bleeding disorder such as hemophelia?
*
Yes
No
How's your digestion?
*
No Problems
Crampy
Gas
Low Appetite
Big Appetite
Diet type
*
Please Select
Omnivore
Vegetarian
Vegan
Junk Food Junkie
Any issues with bowel movements?
Any issues with urination?
Adequate libido?
Excellent
Good
Low
Women: Are you pregnant?
Yes
No
Any additional health concerns or issues?
Questions for the Pindoctor:
Thank you for completing this form.
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