Personal Health History Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityCounty

Post Code

Date of Birth:*

Your Email Address:*

example@example.com

Your Mobile No.*

Area CodePhone Number

Your Occupation:

Your Primary Complaint Details:*

Primary Complaint Started

Date

Your Secondary Complaint Details

Secondary Complaint Started

Date

Current Medical Treatment: Please list any medical examination/investigations you have had e.g. Blood/Stool tests, ECG, Endoscopy, Scans and significant results?

Personal Health History

Fathers Health (Known Genetic issues if applicable)

Mothers Health (Known Genetic issues if applicable)

Current Medication: (if any) Please including HRT/birth control

Please list any Allergies you have:

Please list Accidents/ Injuries / Operations / Broken Bones / Hospitalisation:

Diseases - Please check the diseases you have had.

What is your weight (Imperial or Metric as your prefer)

What is your Height? (Feet or Metres)

What is your BMI (BMI = Weight/Height)

Please enter your BMI

Immunisation: Please check box if you have immunised.

Problems in Childhood.

Health Questions: (Please check each relevant condition).

If you smoke, please indicate for how long in years. Set "0" for non smoker

How many portions of vegetables do you consume daily?

How many portions of fresh fruit do you consume daily?

Do you eat meat?

YesNo

If you are a vegetarian, what is your protein source?

Please indicate

Do you eat dairy products?

YesNo

Do you eat sugary foods?

YesNo

Do you eat Grains/Pulses?

YesNo

WOMEN ONLY: Do you think you maybe pregnant?

YesNo

If you have stopped Menstruating, when was your last period (Approx)

Please advise the number of pregnancies you have had?

Mothers: Please comment on your experiences during pregnancy and labour. e.g. Back Pain, Epidural, Cesarean Section, High Blood Pressure etc.

Please provide all relevant details:

Your Doctors Name:

Please confirm your Doctors name:

Practice Name:

Please confirm the practice name:

Practice Address

Street Address

Street Address Line 2

CityCounty

Post Code

Practice Telephone No.

Area CodePhone Number

To the best of my knowledge, all statements made in this case history are true.

If you are signing on behalf of a minor, please provide your full name and relationship to the patient.

Full NameRelationship

Please check "Yes" or "No" that you are happy to receive occasional newsletters, special offers or vouchers via email? Please note that your contact or health details will NOT be passed to any 3rd party.

YesNo

In order to SAVE and return to your form, you will be prompted to create a Jotform account. Otherwise, please just press Submit and your form will be sent directly to HB Acupuncture.

Please provide 24 hours advance notice if you need to cancel your appointment.

If less than 24 hours notice is given the full fee is charged.

No show appointments will be charged the full fee.

Cash or cheque only.

Please do check with your insurance company for the cover of acupuncture treatment.

Thank you for completing this form. Your Practitioner will ask you
for more details during the consultation.