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English (US)
Traditional Chinese Medicine Health & History Questionnaire
Strength Smith Training Systems LLC
Client Goals
From 1-3 (with 1 being the top priority), please list your primary health goals.
Why have you chosen this order?
General & Contact Information
Name
First Name
Last Name
Age
Date of Birth
Date of Last Physical Exam
Marital Status
Single
Partnered
Married
Separated
Divorced
Widowed
Best Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Doctor
Primary Care Office Phone Number
Primary Care Office Email
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Biomedical Section
Personal Health History
Childhood Illness
Measles
Mumps
Rubella
Chickenpox
Rheumatic Fever
Polio
Immunizations & Dates
Past Year
Past 5 Years
Past 10 Years
10 + Years Ago
Tetanus
Pneumonia
Hepatitis
Influenza
MMR (Measles, Mumps, Rubella)
Covid-19
If Applicable, Mark Each Present or Past Condition
Present Condition
Past Condition
Acid Reflux
AIDS/HIV
Allergies
Anemia
Anorexia
Appendicitis
Asthma
Bloating
Bronchitis
Bulimia
Cancer
Cataracts
Chicken Pox
Cold Sweats
Cold Feet and/or Hands
TMJ
Constipation
Depression
Diabetes
Diarrhea
Difficulty Sleeping
Dizziness
Emphysema
Epilepsy
Fainting
Fatigue
Fever
Fractures
Glaucoma
Goiter
Gonorrhea
Ulcers
Headache
Heart Disease
Hepatitis
Herniated Disc
Herpes
High Blood Pressure
Insomnia
Irritability
Kidney Disease
Liver Disease
Light Sensitivity
Loss of Smell
Loss of Libido
Low Energy
Measles
Whooping Cough
Migraines
Memory Loss
Miscarraige
Mononucleosis
Multiple Sclerosis
Muscle Weakness
Mumps
Osteoporosis
Osteopenia
Pacemaker
Indigestion
Pneumonia
Parkinson's Disease
Polio
Prostate Disorder
Vaginal Infection
Low Blood Pressure
High Cholesterol
Psychiatric Care
Rheumatoid Arthritis
Stroke
Seizures
Shortness of Breath
Nausea
Vertigo
Nervousness/Anxiety
Suicide Attempt
Scoliosis
Thyroid Disorder
Tonsillitis
Tuberculosis
Prosthesis
Any Additional Medical Issues That Doctors Have Diagnosed?
Surgeries (Include Year, Reason, Hospital)
Other Hospitalizations (Include Year, Reason, Hospital)
Have You Ever Had A Blood Transfusion?
Yes
No
Medications & Supplements (Include Name, Dose, Frequency, Reason, Years))
Allergies to Medications (Name, Reaction)
Allergies to Food (Name, Reaction)
Allergies to Environment (Name, Reaction)
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Health Habits & Personal Safety
Exercise
Sedentary (None)
Mild Exercise (Climb Stairs, Walk 3 Blocks)
Occasional Vigorous Exercise (Work or Recreation, less than 4x/week for 30 min)
Regular Vigorous Exercise (Work or Recreation 4x/week for 30 min)
Do You Follow A Specific Diet or Have Diet Restrictions? (Please Describe)
Caffeine Intake
None
Low
Medium
High
Alcohol Intake
None
1-2 per month
1-2 per week
1-2 per day
More than 2 drinks per day
Do You Use Tobacco?
Yes
No
Do You Use Any Recreational Drugs?
Yes
No
Are You Sexually Active?
Yes
No
Are you trying for pregnancy?
Yes
No
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Family Health History
Grandparents (Age, Significant Health Problems)
Father, Mother, Sibling (Age, Significant Health Problems)
Children (Age, Significant Health Problems)
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Pain
Are You Experiencing Any Pain?
Yes
No
If Yes, Please Describe & Rate Pain 0-10 (0=No Pain, 10=Worst Pain Imaginable)
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Mental Health
Is Stress An Issue For You?
Yes
No
Do You Feel Depressed?
Yes
No
Do You Panic When Stressed?
Yes
No
Do You Have Problems With Eating Or Your Appetite?
Yes
No
Do You Cry Frequently?
Yes
No
Have You Ever Attempted Suicide?
Yes
No
Have You Ever Seriously Thought About Hurting Yourself?
Yes
No
Do You Have Trouble Sleeping?
Yes
No
Have You Ever Been To Counseling and/or Therapy?
Yes
No
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Men/Women Specific
Women Only
If Not Applicable Write N/A
Age At Onset Of Menstruation
Date Of Last Menstruation
How Many Days Between Each Period?
Heavy Periods, Irregularity, Spotting, Pain, Discharge?
Yes
No
Number Of Pregnancies
Number Of Live Births
Are You Pregnant Or Breastfeeding?
Yes
No
Have You Had A Hysterectomy or Cesarean?
Yes
No
Any Urinary Tract, Bladder, Or Kidney Infections Within The Last Year?
Yes
No
Any Blood In Urine?
Yes
No
Any Problems With Control Of Urination?
Yes
No
Any Hot Flashes Or Sweating At Night?
Yes
No
Do You Have Menstrual Tension, Pain, Irritability, Or Other Symptoms At Or Around Time Of Your Period?
Yes
No
Experienced Any Recent Breast Tenderness, Lumps, Or Nipple Discharge?
Yes
No
Men Only
If Not Applicable Write N/A
Do You Usually Get Up To Urinate During The Night?
Yes
No
Do You Feel Pain Or Burning With Urination?
Yes
No
Any Blood In Your Urine?
Yes
No
Do You Feel Burning Discharge From Penis?
Yes
No
Has The Force Of Your Urination Decreased?
Yes
No
Have You Had Any Kidney, Bladder, Or Prostate Infections Within The Last 12 Months?
Yes
No
Do You Have Any Problems Emptying Your Bladder Completely?
Yes
No
Any Difficulty With Erection Or Ejaculation?
Yes
No
Any Testicle Pain Or Swelling?
Yes
No
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Additional Problem Areas
Please Select Any Additional Areas That May Be Creating Issues For You
Skin
Head/Neck
Ears
Nose
Throat
Lungs
Chest/Heart
Back
Intestinal
Bladder
Bowel
Circulation
Weight
Energy Level
Ability To Sleep
Other Pains/Discomfort
Labs
Please Upload Your Most Recent & Pertinent Lab Results
Browse Files
Drag and drop files here
Choose a file
***This is only if you have them readily available***
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Traditional Chinese Medicine Section
Temperature-How warm/cold you feel (not degrees) but relative to other people. Check all that apply.
Cold hands or feet
Chills
Cold "In Your Bones"
Areas of numbness
Thirst with no desire to drink
Absence of thirst
Excessive thirst
Thirst for Cold Drinks
Thirst for cold drinks
Night sweats
Unusual sweating
Hot hands, feet, chest
Hot flashes
Hot in the afternoon
Hot at night
Moisture-Your overall body moisture (hair, skin, mouth, bowels etc). Check all that apply.
Dry skin/hair/nails
Dry Eyes
Dry nose/nosebleeds
Dry lips
Dry throat
Dry mouth
Edema/Swelling
Rashes
Itching
Oily skin/hair
Pimples
Weight gain
Weight loss
Digestion. Check all that apply.
Two or less Bowel Movements per day
Three or more bowel movements per day
Stool keeps shape
Stool does not keep shape
Alternating diarrhea/constipation
Indigestion
Gas/Bloating
Belching
Poor Appetite
IBS
Nausea/Vomiting
Bad Breath
Heartburn
Excessive Hunger
Dry Stools
Difficulty passing stool
Tired after bowel movement
Foul smelling stools
Energy. Check all that apply.
Hard to get out of bed in the morning
Energy drops suddenly mid-day
Energy drops after eating
Fatigue
Dependence on caffeine for energy
Wired/feeling ungrounded
Body/Limbs feel heavy
Body/Limbs feel weak
Shortness of. breath
Heart palpitations
High Blood Pressure
Low Blood Pressure
Bleed/Bruise easily
Hard to concentrate
Poor memory
Dizziness/lightheaded
Headaches 1-2 per week
More than 2 headaches per week
Sleep. Check all that apply.
Sleep 1-4 Hours per night
Sleep 4-6 Hours per night
Sleep 7-9 Hours per night
Sleep more than 9 hours per night
Difficulty falling asleep
Waking to urinate between 1-3am
Waking to urinate between 3-5am
Nightmares or disturbed dreams
Restless sleep
Not feeling rested when waking
Emotions. Check all that apply.
Anger
Irritability
Anxiety
Worry
Obsessive thinking
Sadness
Grief
Depression
Joy
Fear
Timid/Shy
Indecision
Flavors & Cravings. Check all that apply.
Sweet (Like Sugar or Starchy foods)
Sour (Like Lemon/Lime)
Spicy (Like Hot Sauce)
Salty
Bitter (Like Coffee or Chocolate)
Eyes, Ears, Nose, Throat. Check all that apply.
Poor Vision
Night blindness
Red eyes
Itchy eyes
Spots in front of eyes
SInus congestion
Clear phlegm
Yellow Phlegm
Green Phlegm
Poor Hearing
High pitched ringing in the ears
Low pitched ringing in the ears
Excessive earwax
Itchy ear canal
Sore throat
Dental problems
Mouth sores
Cough
Urinary. Check all that apply.
Decrease in flow/dribbling
Fluid output is equal to input
Fluid output is more than input
Fluid output is less than input
Difficulty starting/stopping urination
Incontinence
Kidney Stones
Urgent Urination
Frequent Urination
Pain/Burning sensation when urinating
Cloudy Urine
Blood in urine
Other. Check all that apply.
Increase in sex drive
Decrease in sex drive
Premature ejaculation
Infertility
Discharge
Prostate disease
Genital pain
Fibroids/cysts
Hernia
Hemorrhoids
Additional Comments- Is there anything else pertinent that you would like to share?
Food & Nutrition
Please provide some insight into what you eat and drink in a day. Example: How many ounces of water (any coffee, tea, alcohol etc), what your meals typically consist of and how much. We are looking to understand a snapshot of your diet- the more detail you can share the better.
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