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
Yes No
Dizziness
Yes No
Epilepsy
Yes No
Blood/bleeding disorders
Yes No
Diabetes
Yes No
Allergies
Yes No
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
Yes No
Measles
Yes No
Mumps
Yes No
Glandular Fever
Yes No
If yes, at what age did you have Glandular Fever?
Infectious disease such as Hepatitis B or C, HIV, AIDS
Yes No
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
Yes No
Eczema
Yes No
Thyroid problems
Yes No
Diabetes
Yes No
Arthritis
Yes No
Auto immune disease
Yes No
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)
Normal Low Borderline high High Controlled by medication Don't know
Have you had any abnormal blood test results? eg for cholesterol, iron or have you ever been anaemic?
Yes No
If yes, please give details
How would you best describe your energy levels?
Very good Ok Low Variable
How would you describe your stress levels?
High Manageable Low
Do you get headaches or migraines?
Yes No
If Yes, give details
Do you have any recurrent/background health conditions eg skin problems, arthritis?
Yes No
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?
Yes No
Any past or current issues with your bladder/ prostate or kidneys?
Yes No
Thirst – Do you tend to be:
Very thirsty Normally thirsty Not 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 normal I tend to over-heat, I may go red or sweat easily I feel the cold I get alternating hot and cold None of the above
Does environmental temperature or the weather make your symptoms better or worse?
Yes No
Women’s Health & Fertility
Are you menopausal?
Yes No
If you are menopausal:
Do you have any menopausal symptoms?
Yes No
If you are not menopausal:
Tell me about your periods
Do you have PCOS?
Yes No Don't know
Do you have endometriosis?
Yes No Don't know
Please give details of your Contraceptive history
Pregnancy
Are you pregnant?
Yes No
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
