Gabriel Stern L.Ac. R.N

Gabriel Stern L.Ac. R.N.

PATIENT INFORMATION

NameDate

Home Address

CityStateZipPhone

E-mail AddressCell Phone:

Business Address

CityStateZipPhone

Occupation

Place of Birth

Date of BirthAgeHeightWeight

SexMarital Status (Single, Married, Life Partner, Divorced, Widowed)

In Case of Emergency Notify

How did you hear of this office?

Have you ever before tried acupuncture or Chinese herbal medicine?

CHIEF COMPLAINT

What are the main health problems for which you are seeking treatment?

Please rate the extent to which your current complaint affects your daily life (1 = minor; 10 = major)

Please rate your commitment to resolving this problem (1 = minor; 10 = major)

What other forms of treatment have you sought?

PAST MEDICAL HISTORY (check all which apply)

AllergiesCancerDiabetes

HepatitisHigh Blood PressureHeart Disease

SeizuresRheumatic FeverSurgeries

Venereal DiseaseThyroid DiseaseBirth Trauma

VaccinationsChildhood IllnessesAccidents

Significant TraumaMedicationsOther (please specify)

FAMILY MEDICAL HISTORY (check all which apply and specify which blood relative)

CancerHigh Blood PressureHepatitis

Rheumatic FeverInfectious DiseaseDiabetes

Heart DiseaseSeizuresEmotional Disorder

TuberculosisOther (please specify)

LIFESTYLE (please indicate the use and frequency of the following)

CoffeeBlack TeaTobacco

AlcoholCaffeinated BeveragesRecreational Drug

Exercise (please specify type)

MEDICATIONS

Please list any medications and/or supplements you are currently taking

GENERAL HEALTH (please check all that apply)

Poor AppetiteDisturbed SleepInsomnia

FatiguePoor CoordinationWeight Gain

Cold Hands and FeetNight SweatsCold Abdomen

TremorsLarge AppetiteLocalized Weakness

Strong ThirstWeight Loss Fevers

Poor BalanceBruise/Bleed EasilySweat Easily

CravingsChillsSudden Energy Drop

Soft/Brittle NailsCatch Colds EasilyOther (please specify)

SKIN AND HAIR

RashesItchingDandruff

UlcerationsRednessEczema

PsoriasisHair LossHives

PimplesRecent MolesOther (please specify)

HEAD, EYES, EARS, NOSE, THROAT

Dizziness Eye PainBlurred Vision

FloatersSpots in EyesNight Blindness

Ringing in EarsPoor HearingEaraches

HeadachesMigrainesRecurrent Sore Throats

Sores on Lips/TongueDry Mouth/ThroatBleeding Gums

NosebleedsFacial PainJaw Clicking

ToothachesOther (please specify)

CARDIOVASCULAR

Dizziness Low Blood Pressure High Blood Pressure

Irregular Heart Beat FaintingCold Hands/Feet

Chest Pain Swelling of Hands/FeetBlood Clots

Difficulty Breathing PalpitationsOther (please specify)

RESPIRATORY

CoughCoughing BloodAsthma

BronchitisPneumoniaCoughing Phlegm

Pain with deep breathShortness of BreathNasal Congestion

Difficulty breathing when lying downOther (please specify)

GASTROINTESTINAL

NauseaVomitingDiarrhea

ConstipationGasBloating

BelchingAbdominal Pain/CrampsIndigestion

Heartburn/RefluxRetention of Food in StomachLack of Appetite

Excessive AppetiteRectal PainBlack Stools

Blood in StoolHemorrhoidsBad Breath

Sensitive AbdomenChronic Laxative UseOther (please specify)

GENITO-URINARY

Pain on UrinationFrequent UrinationBlood in Urine

Urgency to UrinateUnable to Hold UrineKidney Stones

Decrease in Urine FlowImpotenceSores on Genitals

Waking at Night to UrinateOther (please specify)

REPRODUCTIVE/GYNECOLOGICAL

Age of 1st Period ______Age at menopause ______# Pregnancies ______

# Live Births______# Premature Births ______# Miscarriages/Abortions ___

# days between periods ______# days of flow ______Color of blood ______

Clots (Color ______)Painful MensesIrregular Menses

Premenstrual SymptomsStrong Menstrual OdorVaginal Discharge

Vaginal OdorVaginal DrynessFibroids

Breast Lumps/SwellingsEndometriosisOvarian Cysts

Sexually Transmitted DiseaseUrinary Tract InfectionHot Flashes

Decreased Sex DrivePositive Mammogram/Pap SmearOther (please specify)

MUSCULO-SKELETAL

Neck PainBack PainKnee Pain

Muscle PainFoot/Ankle PainShoulder Pain

Hip PainHand/Wrist PainSciatica

Muscle WeaknessOther Joint/Bone Problems (please specify)

NEURO-PSYCHOLOGICAL

SeizuresDizzinessLoss of Balance

Areas of NumbnessPoor MemoryLack of Coordination

ConcussionDepressionAnxiety

Bad TemperEasily StressedAttempted Suicide

Treated for Emotional ProblemsOther (please specify)

page 1