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