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Personal information

Dr. Ella Woods, DAOM, LA, Dipl. OM
Acupuncture & Herbal Medicine
PERSONAL INFORMATION
TODAY'S DATE:
HEIGHT: WEIGHT: DATE OF BIRTH: AGE: GENDER:

OCCUPATIONAL INFORMATION

OCCUPATIONAL STRESS (PHYSICAL/CHEMICAL/PSYCHOLOGICAL)
PHYSCIAN INFORMATION

PRIMARY DOCTOR: PHONE:

INSURANCE INFORMATION


MISSED APPOINTMENT POLICY
If you need to change or cancel your appointment please do so with 24 hours notice. Failure to do so
will result in being charged full price for missed appointment.
Dr. Ella Woods, DAOM, LA, Dipl. OM
Acupuncture & Herbal Medicine
GENERAL HEALTH INFORMATION
WHAT IS YOUR INTENTION FOR THIS TREATMENT? WHAT ARE YOUR GOALS FOR YOUR HEALTH IN GENERAL? ARE YOU CURRENTLY BEING TREATED FOR A MEDICAL CONDITION? WHAT CONDITION (S) OR ISSUE(S) WOULD YOU LIKE HELP WITH AT THIS OFFICE?: PLEASE DESCRIBE ANY OTHER HEALTH CONCERNS: ARE YOU CURRENTLY EXPERIENCING ANY ACUTE OR CHRONIC PAIN? YES NO IF YES, PLEASE DESCRIBE THE LOCATION, QUALITY AND DURATION OF THE PAIN (S) PLEASE LIST ANY SURGERIES OR HOSPITALIZATIONS (INCLUDE DATES): PLEASE DESCRIBE YOUR EXERCISE ROUTINE: PLEASE DESCRIBE ANY SIGNIFICANT TRAUMAS OR ACCIDENTS (PHYSICAL OR EMOTIONAL): WHAT MEDICATIONS ARE YOU CURRENTLY TAKING? (PLEASE MARK BOTH PAST & PRESENT ONGOING USE) PLEASE LIST ANY OTHERS MEDICATIONS: DO YOU HAVE ANY DRUG OR FOOD ALLERGIES?
PLEASE LIST ANY HERBS OR SUPPLEMENTS YOU ARE CURRENTLY TAKING (not already listed above):
PLEASE LIST THE FOODS THAT YOU AVOID OR TRY TO REDUCE AND WHY:
PLEASE DESCRIBE YOUR TYPICAL DAILY FOOD & DRINK INTAKE BELOW:
BREAKFAST
LUNCH
Dr. Ella Woods, DAOM, LA, Dipl. OM
Acupuncture & Herbal Medicine
FAMILY HISTORY: (PLEASE MARK EACH BOX THAT APPLIES FOR A FAMILY MEMBER OR YOURSELF)
CONDITION
CONDITION
PERSONAL HABITS (PLEASE MARK ANY USE OF THE FOLLOWING NOW OR IN THE PAST)
Dr. Ella Woods, DAOM, LA, Dipl. OM
Acupuncture & Herbal Medicine
HAVE YOU HAD ANY OF THE FOLLOWING SYPTOMS OR CONDITIONS?
(PLEASE CHECK ALL THAT APPLY)
Digestive
Respiratory
Skin / Hair
Cardiovascular
Musculoskeletal
Shoulder pain
Head & Neck
Joint / bone problems
Genito-urinary
Nose/Throat
Neurological
Infection Screening
Dr. Ella Woods, DAOM, LA, Dipl. OM
Acupuncture & Herbal Medicine
Psychological / Behavioral
Gynecological (cont)
Gynecological (cont)
Gynecological

ADDITIONAL COMMENTS:

Source: http://www.acupunctureworks.biz/documents/questionnaire.pdf

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