2. Have you ever been hospitalized? Yes No. 3. Have you visited a doctor in the last three (3) years? Yes No
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1 Supporting Information TEXT 1S MEDICAL QUESTIONNAIRE Full Name Address Address Weight Marital Status Occupation Height Fertility Status Statement of Health The Medical Examiner is requested to ask the following questions or to review them if they have been answered previously. Give details and dated if any of the questions below are answered with Yes 1. Do you currently have any health problems? 2. Have you ever been hospitalized? 3. Have you visited a doctor in the last three (3) years? 4. Do you suffer from or have you ever suffered from any of the following (a) Tuberculosis (b) Leprosy (c) Hepatitis (seecify type) (d) Typhoid, dysentery or any other infectious or Communicable diseases (e) AIDS or AIDS related conditions, any Immune Deficiency Syndrome (f) Genetic or Familial Disorders (g) Deafness or Chronic Ear Disease (h) Blindness or Eye Disease (i) Any cancerous disease: benign/malignant (j) Headache migraine, epilepsy or dizziness (k) Nervous or mental illness or disorders (l) Any allergies, asthma or pulmonary disease (m) Cardiovascular diseases, arterial Hypertension (n) Liver, stomach or intestinal diseases (o) Diabetes or other hormone diseases 1 / 23
2 (p) Urinary tract disease (q) Venereal diseases (r) Rheumatism, Muscle, Joint or bone diseases (s) Skin diseases (t) Consmetic operations (u) Any other illness or disorder If Yes to any of the above, please give details and dates. 5. How old do you first menarche? 6. How long of your menstrual cycle? 7. What about your menstrual quality? Color red, without blood clot Color bleak, no congestion Color bleak, with blood clot Color red, with blood clot 8. Do you have any dysmenorrheal history? 9. When do you feel pain in menstrual period? Before menstruation During menstruation After menstruation 10. What s duration of your dysmenorrheal? 1 Day 2 Days 3 Days 4 Days 11. How long do you suffer dysmenorrheal? 1 Year 2-3 Years 4-5 Years 6 Years 12. What type of dysmenorrhea do you think you suffered? Primary dysmenorrhea Secondary dysmenorrhea Uncertain 13. What do you think the reason caused dysmenorrhea? High pressure Nervous in menstruation Not pay attention to diet and keep warm in menstruation Genetic factors Irregular sleep Environmental factors 14. How symptoms accompany with your dysmenorrhea? 2 / 23
3 Abdominal pain, distension, lumbago Nausea, vomiting and diarrhea Anxiety Breast distending pain Weak Headache or dizziness 15. What dysmenorrheal degree do you think you suffered? Mild: Not to affect the life Moderate: Affect the life Severe: Affect the life severely 16. How do you to deal with dysmenorrhea? Not to do anything, just rest Visit a doctor Take analgesics Do some exercises Take tradition Chinese medicine The Medical Examiner is required to examine the applicant and to answer the following questions. Give details and dates if any of the questions below are answered with Yes. 17. Gynecological examination-any signs of abnormalities? 18. B-ultrasound examination-any signs of abnormalities? 19. Symptoms in traditional Chinese medicine-any signs of Qi stagnation syndrome? 20. Comments Important: Please attach original results of the following 3 / 23
4 (i) Routine Blood and urine test (ii) B-ultrasound test Medical Examiner s Details and Declaration Full Name and Qualifications Specialty Address Address Telephone I hereby confirm that I have identified, questioned and examined the applicant and have answered all questions to the best of my knowledge and in good faith. Signature of Medical Examiner Place and Date of Examination Name and Stamp of Medical Examiner 4 / 23
5 Table 1S. Clinical Efficacy Assessment standard of Primary Dysmenorrhea Symptoms Scores Abdominal pain during the menstrual cycle or before and after menstruation Yes 5; No 0 Obviously abdominal pain Yes 5.5; No 0 Abdominal pain is unbearable Yes 6; No 0 Abdominal pain is unable to sit down or sleep at ease Yes 1; No 0 Abdominal pain effects of work and study Yes 1; No 0 Abdominal pain and need bed rest Yes 1; No 0 Using the general measures and relief the pain Yes 0.5; No 0 Using the general measures and afford no relief the pain Yes 1; No 0 Pale Yes 0.5; No 0 Cold sweat Yes 1; No 0 Peripheral coldness Yes 1; No 0 Schock Yes 2; No 0 With the waist ache Yes 0.5; No 0 With the nausea and vomiting Yes 0.5; No 0 With anal bulge Yes 0.5; No 0 Pain duration add one day the score add 0.5 Yes days 0.5; No 0 5 / 23
6 No. Table 2S. UPLC - MS analytic results of Xiang-Fu-Si-Wu Formula t R min Ion mode Measured Mass(m/z) Calc. Mass(m/z) Error (ppm) Elemental composition neg C 7 H 5 O neg C 9 H 7 O neg C 16 H 17 O neg C 23 H 27 O neg C 23 H 27 O neg C 10 H 9 O neg C 15 H 21 O neg C 12 H 11 O neg C 15 H 19 O neg C 16 H 31 O pos C 20 H 24 NO pos C 20 H 20 NO pos C 21 H 24 NO pos C 19 H 18 NO pos C 21 H 26 NO pos C 21 H 26 NO pos C 22 H 28 NO 4 + Compound Quantit ative ions Content (mg/g dry extract) Gallic acid a Caffeic acid a Chlorogenic acid a Albiflorin a Peoniflorin a Ferulaic acid a Neolazppaic acid b 3-butylidene-7-hydrox yphthalide b Costunolide b Palmitic acid b Tetrahydrocolumbami ne a Protopine a Allocryptopine b Tetrahydrocoptisine a Tetrahydropalmatine a Glaucine b Corydaline a pos C 20 H 18 NO 4 Berberine a pos C 22 H 24 NO 4 Dehydrocorydaline a pos C 15 H 20 NO 2 Costuslactone b a Confirmed by reference compounds. b Relative content to internal standard. 6 / 23
7 Analyte Table 3S. Precursor/product ion pairs and parameters for MRM of the marker compounds Retention time (min) [M + H] + (m/z) MRM transitions (Precursor product) Cone voltage (V) Collision energy (ev) 1 Phytosphingosine LysoPC (18:3) LysoPC (16:1) LysoPC (20:4) LysoPC (18:2) LysoPC (16:0) b LysoPC (18:1) Estrone b Hydroxyprogesterone Myristoylglycine Dihydrocortisol b Palmitoylglycine Phytosphingosine Sphingosine LysoPC (10:0) IS / 23
8 Figure 1S. UPLC - ESI- MS base peak intensity (BPI) chromatograms at the positive and negative ion mode of Xiang-Fu-Si-Wu Formula 8 / 23
9 Figure 2S. Peak and corresponding mass spectrum of potential markers (Metabolites 1-15). 9 / 23
10 10 / 23
11 11 / 23
12 12 / 23
13 13 / 23
14 14 / 23
15 15 / 23
16 16 / 23
17 17 / 23
18 18 / 23
19 19 / 23
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Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
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Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
New Patient Intake Form. Personal Information. Name Date. Address City State Zip. Occupation Referred by. I prefer to be contacted by: Phone ( )
New Patient Intake Form Personal Information Name Date Address City State Zip Occupation Referred by I prefer to be contacted by: Phone ( ) Email Marital Status: Married Single Divorced Widowed Partnered
Student Full Name: Date of Birth:
Student Medical Form This form is to be completed for new students upon admission, and returning students prior to starting grades 3, 6, and 9. Students participating in athletics must complete form every
INFORMATION/APPLICATION FOR CARE
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New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Adult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
MEDICAL DATA SHEET For Patients 18 years of age and older
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Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C
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PATIENT INFORMATION FORM (WOMEN ONLY)
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55 S. Main Street, Driggs, ID (208)
Elements of Health 55 S. Main Street, Driggs, ID 83422 (208) 920-0312 Name: (first) (middle) (last) Date: / / Address: Phone: / street address city zipcode home / cell Date of Birth: / / Age: Gender: M/F
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
CHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status: