504 Hamburg Turnpike 24 Nautilus Drive

TCM ACUPUNCTURE 504 Hamburg Turnpike 24 Nautilus Drive Suite 205, Wayne, NJ 07470 Suite 5, Manahawkin, NJ 08050 Office: 973-595-8899 Fax: 973-595-5855 Office: 609-661-9657 Confidential Health History Questionnaire

LIST AREAS OF PAIN AND OTHER CONDITIONS TO BE TREATED: 1. ______How long have you had this: ______days/weeks/months/years? Is this a flare up? Yes/No How frequently do you experience this condition: constant/daily/monthly/seasonally What is the Intensity of your Discomfort: 1 – 10 (10 being most severe): _____ Is your pain or discomfort: ( ) Sharp ( ) Burning ( ) Aching ( ) Cramping ( ) Tight Have you had an ( ) X-ray ( ) MRI ( ) CAT scan ( )other: ______Treating Physicians (circle): MD PT ORTHO CHIRO other:______2. ______How long have you had this: ______days/weeks/months/years. Is this a flare up? Yes/No How frequently do you experience this condition: constant/daily/monthly/seasonally What is the Intensity of your Discomfort: 1 – 10 (10 being most severe): _____ Is your pain or discomfort: ( ) Sharp ( ) Burning ( ) Aching ( ) Cramping ( ) Tight Have you had an ( ) X-ray ( ) MRI ( ) CAT scan ( )other: ______Treating Physicians (circle): MD PT ORTHO CHIRO other:______Are any of the above conditions due to an automobile accident? YES/NO Is there an active personal injury case? YES/NO

Pain Management: CHECK ALL areas where you experience pain and discomfort: HEAD ( ) temples ( ) forehead ( ) sinuses ( ) jaw ( ) back of head TRUNK ( ) neck ( ) shoulders ( ) chest ( ) upper back ( ) mid-back ( ) low back ( ) abdomen ( ) intestines ( ) hips ( ) pelvic/groin ARMS ( ) upper arm ( ) elbows ( ) forearms ( ) wrists ( ) hands & fingers LEGS ( ) thighs ( ) knees ( ) calves ( ) ankles ( ) feet &toes

Medical History: Month and year of your last Physical: _____/_____ Bloodwork: _____/_____ Month and year of your last Colonoscopy: _____/______Have not had one CHECK any condition YOU have had or currently have. ( ) Addiction: ______( ) Ebstein Barr Virus, EBV ( ) Meningitis, viral/bacterial ( ) Allergies ( ) Emphysema ( ) Migraines ( ) Anxiety / Panic Attacks ( ) Epilepsy / Seizures ( ) Mononucleosis ( ) Asthma ( ) Tinnitus: Hi/Low pitch ( ) Multiple Sclerosis, MS ( ) Arthritis ( ) Headaches: tension / cluster ( ) Osteoporosis ( ) Bursitis: ______( ) Heart Disease: heart attack ( ) Pneumonia ( ) Cancer: ______( ) Hepatitis A/B/C, chronic ( ) Polio ( ) Cancer: ______( ) High Blood Pressure ( ) Psoriasis / Eczema ( ) Chicken Pox ( ) High Cholesterol: _____ ( ) Reflux / Ulcers ( ) Crohns / Colitis ( ) Eating Disorder ( ) Lupus ( ) Chronic Fatigue ( ) HIV / AIDS ( ) Lymes Disease ( ) Chronic Bronchitis ( ) Irritable Bowel ( ) Stroke ( ) COPD ( ) Diabetes, Type I, II ( ) Tendonitis ( ) Depression ( ) Diverticulitis ( ) Thyroid: hypo / hyper Confidential Health History Questionnaire

Family History: Check if your family members have had the conditions below: Heart Attack/Stroke Cancer High Blood Pressure High Cholesterol Depression Mother Father ______

Please list ALL known ALLERGIES: 1. ______3. ______2. ______4. ______

Medications & Supplements Dosage What Condition _ How Long 1.______2. ______3. ______4. ______Use back of paper if you need extra room. ____ See back of paper (check if needed)

Please list your surgeries and/or hospitalizations Year For what condition___ 1.______2. ______3. ______4. ______

Women Only: MENSTRUAL AND FERTILITY INFORMATION: Age of first menstruation: ______Could you be pregnant? YES/NO Days of Cycle (period to period): # ______Current Contraception: ______Average number of days you bleed: ______Pregnancies: _____ Miscarriages: _____ Fertility specialist:______Clomid ____x IUI____x IVF____x CHECK if you have or had any of these conditions? ( ) irregular cycles ( ) pain between cycles ( ) endometriosis ( ) yeast infections ( ) D & C ( ) STD ( ) fibrocystic breasts ( ) ovarian cysts ( ) C-section ( ) pain during intercourse ( ) abnormal pap smear ( ) spotting between cycles ( ) hysterectomy: partial or full ( ) Menopausal changes Mark a “B” if symptom occurs Before your cycle begins, “D” if during, and “A” if after. ( ) anxiety ( ) headaches ( ) breast tenderness ( ) heavy bleeding ( ) water retention ( ) clots: small/large ( ) abdominal pain ( ) irritability ( ) depression ( ) nausea/vomiting ( ) low back pain ( ) low energy

Men Only: Please check if you have any of the following conditions: ( ) Enlarged Prostate ( ) Impotence ( ) Premature ejaculation ( ) Testicular pain ( ) Low sperm count ( ) Low sex drive ( ) PSA:______( ) Low testosterone ( ) Erectile dysfunction ( ) STD

BRING IN ALL TESTS, REPORTS AND BLOODWORK TO YOUR FIRST VISIT.

Patient/Guardian Signature: ______Print Name: ______