<p>Lam Clinic of Traditional Chinese Medicine 2516 Broadway • Boulder, Colorado 80304 • 303.444.2357</p><p>Welcome to the Lam Clinic of Traditional Chinese Medicine. To help us provide you with the best possible care, please complete this form. This information will remain confidential.</p><p>Your Name: Date of Birth: / / Age:</p><p>❏ Male ❏ Female Social Security Number:</p><p>Street Address: City: State: Zip:</p><p>Phone (day): Phone (evening): Occupation:</p><p>Email: </p><p>In case of emergency, contact: Name: Relationship: Phone: Street Address: City: State: Zip:</p><p>How did you hear about us?</p><p>Please describe your reason for today’s visit:</p><p>Have you ever had this difficulty or a similar one before? If yes, please explain:</p><p>Is it getting ❏ better ❏ worse or ❏ staying about the same?</p><p>What seems to make it feel better?</p><p>What seems to make it feel worse?</p><p>Are you being treated elsewhere? ❏ Yes ❏ No By whom?</p><p>What was the diagnosis?</p><p>What were the results of treatment?</p><p>Are you currently taking prescription medicines, herbs, or supplements? ❏ Yes ❏ No If so, which ones? Personal Medical History ❏ Thyroid Disorders Please check appliable boxes if you have had any ❏ Trauma (falls, accidents) of these medical conditions: ❏ Tuberculosis ❏ Addiction (drugs or alcohol) ❏ Ulcers ❏ AIDS/ARC ❏ Other: ______❏ Allergies ______❏ Anemia ❏ Appendicitis ❏ Arteriosclerosis Family Medical History ❏ Asthma Please check appliable boxes if anyone in your ❏ Bleeding Tendency family has these conditions: ❏ Blood Pressure (low) ❏ Blood Pressure (high) ❏ Alcoholism ❏ Cancer ❏ Allergies (list) ❏ Chicken Pox ______❏ Diabetes ❏ Arteriosclerosis ❏ Digestive Disorder ❏ Asthma ❏ Emotional Difficulties ❏ Cancer ❏ Emphysema ❏ Diabetes ❏ Epilepsy ❏ Heart Disease ❏ Fatigue ❏ High Blood Pressure ❏ Gout ❏ Seizures ❏ Headaches ❏ Stroke ❏ Heart Disease ❏ Hepatitis ❏ Herpes Please describe what you eat in a typical day: Breakfast: ❏ HIV positive ❏ Hypoglycemia ❏ Injuries Lunch: ❏ Insomnia ❏ Intestinal Parasites Dinner: ❏ Measles ❏ Multiple Sclerosis ❏ Mumps Snacks: ❏ Pacemaker ❏ Polio ❏ Rheumatic Fever Medications: ❏ Scarlet Fever ❏ Sexually Transmitted Disease Coffee: ❏ Stroke Cigarettes: ❏ Surgery (list) ______Marijuana: ______Recreational drugs: ______Symptom Review Urinary Please put one check by a symptom you ❏ Frequent ❏ Nighttime ❏ Cloudy sometimes experience; use two checks for ❏ Difficult ❏ Painful ❏ Bleeding❏ Other those which often occur, and three checks for ❏ Discharge symptoms that are a major concern. Throat Heart and Chest ❏ Sore throat ❏ Other ❏ ❏ ❏ Headaches Palpitations Nervousness ❏ Hoarseness ❏ ❏ ❏ Dizziness High blood pressure ❏ Difficulty swallowing Tremors ❏ ❏ Memory loss Tightness in chest Skin ❏ ❏ ❏ Convulsions Other Low blood ❏ Rashes ❏ Dryness pressure ❏ Moles or lumps that change ❏ Lumps that don’t change Neurological ❏ Excessive sweating ❏ Night sweating ❏ Numbness or tingling ❏ Other ❏ Nerve ❏ Seldom sweat ❏ Other pain ❏ ❏ Difficulty lying flat Lack of coordination Respiration ❏ Difficulty inhaling ❏ Difficulty exhaling Eyes ❏ Cough ❏ Blurred vision ❏ Eyelid problem ❏ Other ❏ ❏ Floaters Pain Digestion ❏ Excessive appetite ❏ Normal Circulation ❏ Low appetite ❏ Other ❏ Pain ❏ Bruise easily ❏ Bleed easily ❏ Always thirsty ❏ Jaw problems ❏ Cold limbs, hands, or feet ❏ Hot palms ❏ Never thirsty ❏ Nausea ❏ Overall feeling of warmth ❏ Stomach or abdominal pain ❏ Overall feeling of cold ❏ Other Bowel Movement ❏ ❏ Sleep Diarrhea Constipation ❏ ❏ Insomnia ❏ Drowsiness Rectal bleeding ❏ ❏ ❏ Excessive dreaming ❏ Other Colon problems Bleeding ❏ Pain Ears ❏ Hearing difficulty ❏ Other ❏ Earaches ❏ Ringing (circle Low/High)</p><p>Nose ❏ Sinus trouble ❏ Congestion </p><p>Mouth ❏ Gum problems ❏ Dental problems ❏ Unusual tastes ❏ Tongue problems Women Only Men Only Are you or might you be pregnant? Do you experience… ❏ Yes ❏ No ❏ Maybe. ❏ Reduced libido ❏ Urinary frequency If yes, what month?______❏ Excessive libido ❏ Impotence What method of birth control do you use? ❏ Premature ejaculation ❏ Genital discharge ______❏ Seminal emission (spontaneous ejaculation Do you have regular PAP tests? ❏ Yes ❏ No. without sexual stimulation) How often?______❏ Pain associated with genitals Are you experiencing unusually low or high ❏ Other: sexual desire? Other difficulties? Age at first menstruation: Age at menopause: Date of first day of last menstrual cycle: Number of days of last menstruation (bleeding): Usual length of monthly cycle (from first day of bleeding until day before next bleeding): Thank you for completing this form. If you Are your periods… need additional space to list health history, ❏ ❏ ❏ ❏ Irregular: Short Long Variable please use the space below. ❏ Light blood ❏ Thick blood ❏ Watery blood ❏ Heavy bleeding ❏ Heavy clotting ❏ Light bleeding ❏ Stop and start again ❏ Dark blood… ❏ Red ❏ Purple ❏ Brown ❏ Spotting… ❏ Before ❏ After ❏ Mid-cycle ❏ Painful: ❏ Before ❏ During ❏ After ❏ Mid-cycle Relieved by… ❏ Heat ❏ Cold ❏ Pressure Do you have any pre-menstrual symptoms? ❏ Painful or swollen breasts ❏ Nausea ❏ Irritability ❏ Cramps or pain ❏ Crying ❏ Depression ❏ Other: ❏ Food cravings: Vaginal discharge ❏ Normal ❏ Bad odor ❏ Watery ❏ Itching ❏ Thick ❏ Dryness ❏ Yellow ❏ Other: ❏ Clear or white Gynecological surgeries or problems (please describe) ❏ Ovaries: ❏ Vagina: ❏ Uterus: ❏ Breasts: ❏ Fallopian Tubes: ❏ Other: Pregnancies Total number: Complications: Number of children: Abortions or miscarriages: How long ago was your last pregnancy? </p>