Note from Judy Bowen-Jones:

    Usually I would take full details of your current health issues and past medical history face to face, as part of your initial consultation. But because of Covid-19, we have been instructed to keep any close contact to a minimum. So, for the time being, I am asking clients to complete this online questionnaire and submit it in advance of their appointment. In this way, we can reserve face to face time for physical examination and treatment.

    On receipt of your completed questionnaire, I will call you briefly to discuss any questions.

    Before your appointment you will also be required to complete separate Covid-19 Screening and Consent Forms.

    Main condition:

    Please describe the main condition/symptom you are seeking acupuncture for at the present time

    Other conditions:

    Past Medical History:

    Do you (does the patient, if you are completing for an under 16) currently suffer from, or have you ever suffered from any of the following conditions or illnesses:

    Heart problems/endocarditis

    YesNo

    Dizziness

    YesNo

    Epilepsy

    YesNo

    Blood/bleeding disorders

    YesNo

    Diabetes

    YesNo

    Allergies

    YesNo

    If you have answered yes to any of the questions above, please give details in the box below

    Please indicate if you have had any of the following:

    Chicken Pox

    YesNo

    Measles

    YesNo

    Mumps

    YesNo

    Glandular Fever

    YesNo

    If yes, at what age did you have Glandular Fever?

    Infectious disease such as Hepatitis B or C, HIV, AIDS

    YesNo

    If yes, please give details here

    NB: All patients will also be required to complete a separate Covid-19 Screening Form

    Please give brief details (including your approximate age at the time) of any illnesses, operations, accidents, broken bones, trauma, illness abroad, serious gastrointestinal upset, bad insect bites etc

    Family History:

    Does anyone in your immediate family (parents and siblings) suffer from:

    Asthma

    YesNo

    Eczema

    YesNo

    Thyroid problems

    YesNo

    Diabetes

    YesNo

    Arthritis

    YesNo

    Auto immune disease

    YesNo

    Medication:

    Please give details of any medications or supplements you are taking:

    General Information & Test Results:

    Is your blood pressure: (please tick the one that best applies)

    NormalLowBorderline highHighControlled by medicationDon't know

    Have you had any abnormal blood test results? eg for cholesterol, iron or have you ever been anaemic?

    YesNo

    If yes, please give details

    How would you best describe your energy levels?

    Very goodOkLowVariable

    How would you describe your stress levels?

    HighManageableLow

    Do you get headaches or migraines?

    YesNo

    If Yes, give details

    Do you have any recurrent/background health conditions eg skin problems, arthritis?

    YesNo

    Please give details

    How is your sleep?

    What forms of exercise do you take, how often?

    Please tell me a little about your appetite and diet.

    Do you have any digestive problems eg heartburn, IBS, indigestion, bloating, constipation, loose bowels etc?

    YesNo

    Any past or current issues with your bladder/ prostate or kidneys?

    YesNo

    Thirst - Do you tend to be:

    Very thirstyNormally thirstyNot very thirsty

    How much water do you drink a day?

    On average, how many caffeinated drinks do you consume per day?

    How many carbonated drinks do you consume per day?

    How many units of alcohol do you consume per week?

    Body temperature - Which of the following best applies to you:

    Generally normalI tend to over-heat, I may go red or sweat easilyI feel the coldI get alternating hot and coldNone of the above

    Does environmental temperature or the weather make your symptoms better or worse?

    YesNo

    Women’s Health & Fertility

    Are you menopausal?

    YesNo

    If you are menopausal:

    Do you have any menopausal symptoms?

    YesNo

    If you are not menopausal:

    Tell me about your periods

    Do you have PCOS?

    YesNoDon't know

    Do you have endometriosis?

    YesNoDon't know

    Please give details of your Contraceptive history

    Pregnancy

    Are you pregnant?

    YesNo

    If you are pregnant, please give details

    Finally, anything else you would like to mention, that has not been covered already

    Sincere thanks for taking the time to complete this questionnaire. For your acupuncture treatment to be effective, it is important that I have as full a picture of you and your health as possible.

    Once I have received this, I will call you for a brief chat.

    I look forward to meeting you.

    Best wishes

    Judy Bowen-Jones