Narrye Caldwell, L.Ac. 1685 Westwood Dr. Suite #9 San Jose, CA. (408) 489-8268
Please Check any of the following that are part of your history: (note if current or past)
asthma allergies frequent colds sinus problems chronic sore throats ear infections frequent antibiotic use
heart disease palpitations irregular heart beat insomnia high blood pressure edema
diabetes hypoglycemia chronic digestive problems colitis irritable bowel syndrome ulcers heartburn food sensitivities or allergies gall bladder disease
PMS menstrual problems abortion miscarriage infertility endometriosis fibroids fibrocystic breasts hysterectomy
mononucleosis HIV+ hepatitis herpes chronic fatigue fibromyalgia
cancer arthritis eczema/psoriasis
neurological disorders headaches/migraines muscle tension dizziness/vertigo vision problems back/neck pain joint pain
kidney infection kidney stones ringing in the ears thinning hair memory loss
prostate problems urinary problems depression anxiety/panic mental disorder
Are any of the following habits part of your lifestyle now or in the past?
Do you adhere to any special diet? How would you describe your diet and eating habits? Is there anything you would like to change?
What are you exercise habits?
How would you rate the stress in your life: High, Medium or Low?
Are there any other concerns you would like to talk about?
My signature or acceptance authorizes Narrye Caldwell L.Ac., to treat me with acupuncture, medicinal herbs, and other modalities within the licensure granted by the Medical Quality Assurance Board of the State of California. I understand that I am fully responsible for payment, and that if my insurance does not cover services, I will be responsible for payment of all fees.
Signature Date