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
