General Patient Information

Name____________________________________________________ Date_______________

Address______________________________________________________________________ City______________________________ State__________________ Zip__________________

Social Security #_____________________________ Date of Birth________________________

Age_________ Gender: Male_______ Female_______ Married_________ Single____________

Home Phone: ___________________Cell Phone: _________________ Work Phone: ________

E-mail address: ___________________________

Place of Employment___________________________ Occupation ________________________

Emergency Contact_______________________________ Phone_________________________

How did you hear about us? Referred by_____________________________________________

Web-site_______ Drive-by_______ Other_________________________

Current Medications: _____________________________________________________________

______________________________________________________________________________

Current Supplements (vitamins, herbs, etc.):____________________________________________

______________________________________________________________________________

Major Complaint(s), in order of significance to you:

1. Major Complaint: ____________________________________________________________

2. Secondary Complaint: _________________________________________________________

3. Other Complaint: _____________________________________________________________

4. Other Complaint: _____________________________________________________________

How do these conditions impair your daily activities? ___________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Patient Medical History

How was your childhood health? ___________________________________________________

    Surgeries: 1._____________________ 2.___________________3._______________________

                      4. ____________________ 5.­­­­­­­­­­­­­­­­­­­­­___________________6.______________________

Recent tests: (please bring the copy of those)

Physical       Cholesterol      Blood      Prostate      HIV      STD       Pap smears      Mammography

Other _________________________________________________________________________                      

Check any you have had in the past:

○Diabetes                   ○Allergies                      ○ Glaucoma                                 ○ Rheumatic Fever

○Heart Disease          ○Thyroid Disorder         ○ Asthma                                      ○ Pneumonia

○CVA (stroke)            ○Tuberculosis               ○ Emphysema                              ○ Jaundice

○Vein Condition         ○Gonorrhea                   ○ Mumps                                      ○ Bleeding tendency

○ Syphilis                   ○ Measles                       ○ Chicken Pox                            ○ Nervous Disorder

○ Meningitis               ○HIV                               ○ Polio                                         ○ Mononucleosis

○ Epilepsy                  ○ Cancer                          ○ Hepatitis                                 ○ Multiple Sclerosis

○ Paralysis                 ○Migraines                      ○ High Blood Pressure               ○ other lung illness

○ other Liver illness    ○ other kidney illness      ○ other spleen illness               ○ other stomach illness

○ other heart illness   

Other: ________________________________________________________________________

Accident injury: _________________________________________________________________

Habits/ Excess usage

o Alcohol           o Chocolate          o Cigarretes           o Coffee           o Soda        o Drug     o Food

oExercise          o Salt                     o Sugar                  o Tea               o Sex          o Other _______

Family Medical History

Check the following that have occurred in your blood relatives:

○ Diabetes                ○ Cancer                  ○ Heart Disease                         ○ High Blood Pressure

○ Allergies                ○ Tuberculosis         ○ Obesity                                    ○ Bleeding Tendency

○ Kidney Disease     ○ Alcoholism            ○ Nervous Illness                        ○ Mental Illness

○ Stroke ○Other______________________________________________________

Patient Profile

Please clearly mark any areas of pain on the diagram on the following page:

How your pain is ?

○ Sharp     ○ Burning    ○ Aching    ○ Cramping    ○ Dull    ○ Moving    ○ Fixed    ○ Other:__________

What make your pain better?

○ Cold           ○ Heat             ○ Pressure           ○ Exercise       Other: _____________________________________

What make your pain worse?

○ Pressure         ○ Cold        ○ Heat       ○ Exercise    ○ Other ________________________

Please check any of the following that is related  to you:                                 

Overall Temperature (Kidney function):

○ Cold hands                               ○ Cold feet                ○ Sweaty hands                ○ Sweaty feet

○ Afternoon flushes                     ○ Hot flushes            ○ Night sweats                  ○ Hot sensation

○ Cold sensation                         ○ Perspire easily       ○ Lack of perspiration        ○ Thirsty

○ Low energy ○vaginal dryness

Eyes (Liver function):

○ Itchy                                           ○ Bloodshot               ○ Hot                                   ○ Dry

○ Watery                                        ○ Pressure                o Blurry vision                     ○ See floaters

Overall Energy (Kidney, Spleen, Lung function):

○ Easily catch colds                   ○ General weakness      ○ Shortness of breath         ○ Fatigue

Blood (Liver Spleen, Heart function):

○ dizziness                                    ○ poor memory             ○ pale skin       ○ fatigue       ○ graying hair

Heart function:

○ palpitations                                ○ anxiety                       ○ restlessness      ○ sores on tongue

○ mental confusion                       ○ vivid dreams              ○ chest pain          ○ insomnia

○ mental fogginess                       ○ wake up tired                                           ○ mental sluggishness

Lung function:

○ cough                 ○ sinus congestion               ○ nose bleeds                           ○ dry mouth

○ dry throat           ○ dry nose                             ○ dry skin                                  ○ sneezing

○ body aches        ○ stiff neck                            ○ stiff shoulders ○sore throat     o Easy sweat

○ melancholy        ○ chills & fever                      ○ difficult breathing

○ nasal discharge /color:__________________________________________________________

○ allergies/to what:______________________________________________________________

○ headache/location:_____________________________________________________________

○ smoke cigarettes/#per day:_______________________________________________________

Spleen function:

○ low appetite                ○ bloating                  ○ abrupt weight change          ○ gas

○ gurgling stomach        ○ easily bruise         ○ fatigue after eating               ○ hemorrhoids

○ over-thinking               ○  worry                    ○ organ prolapsed                   ○ constipation

○ loose stools                ○ diarrhea                                                                 ○ mucous in stools

○ incomplete stools       ○ undigested food in stools                                     ○ blood in stools

Dampness:

○ swollen hands          ○ swollen feet       ○ swollen joints                    ○ chest congestion

○ nausea                     ○snoring               ○  heavy body sensation      ○ snoring

Stomach function:

○ burning                     ○ bad breath                            ○ very large appetite ○canker sores

○heartburn                  ○acid reflux                             ○ bleeding or swollen gums ○ulcer

○belching                    ○hiccups                                 ○ stomach pain ○vomiting

Liver/Gallbladder function:

○ chest pain                ○anger easily              ○ tightness in chest                ○ bitter taste

○ frustration                 ○depression                ○ frequent headaches             ○ irritability

○ tingling                      ○ numbness                ○ muscles spasms                ○ seizures

○ twitching                   ○ convulsions              ○ lump in throat                       ○ muscle tension

○ drink alcohol             ○ gall-stones               ○ ringing in ears                      ○ sexual disease

○ alternating diarrhea and constipation          o  indecision

Kidney/Bladder function:

○ sore/weak knees     ○ low back pain           ○ easily broken bones             ○ memory problems

○ excessive hair loss  ○ kidney stones          ○ lack of bladder control        ○ fearful

○ high libido                 ○ low libido                  ○ normal libido

Urination:

○ frequent                    ○ urgent                       ○ dark yellow color                  ○ reddish color

○ clear color                ○ scanty                      ○ profuse                                 ○ strong odor

○ burning                     ○ painful                      ○ difficult                                  ○ cloudy

Men only:

○ testicular pain          ○ swollen testes          ○ premature ejaculation          ○ impotence

○ coldness or numbness in genitalia              o low libido

○  other:________________________________________________________________________

Women only:

Age of first menses: _____________    Age of menopause: _______

Number of pregnancies: __________    no. of life births ___________ no. of abortion _________

Are you pregnant now? ___________

Vaginal discharge: color: __________   thin/thick: __________            strong odor: ____________

Bleeding: Amount _______________    color: __________ clots: _________cramps: __________

Frequency: ____________________     how long does it last? ____________________________

Do you experience any of the following pre-menstrual syndromes?

○ nausea                     ○ food cravings                       ○ depression                           ○ vomiting

○ headaches               ○ irritability                               ○ water retention                     ○ migraines

○ anxiety                      ○ cramps                                ○ breast tenderness               ○ moody

Please, print out this form, fill it in, and bring it with you to your appointment.