~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information

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1 Patient General Information Name: (first) (middle) (last) Date of Birth: / / (mo) (day) (year) 中 文名字 : Gender: Occupation: Address: (street, apt) Phone #: (city, state, zip code) Emergency Contact: Phone #: How did you hear about us? Reasons for visit, in the order of significance to you: Signature: Date: 1 of 7

2 Patient Consent Form I,, hereby consent to be treated with acupuncture and herbal medicine by Li Lin at Southern Village Acupuncture and Herbology LLC. I understand that acupuncture is performed by the insertion of fine needles into specific points of the body with the intent of improving body functions and/or relieving pain. I understand that only pre-sterilized, disposable needles will be used. I understand that the needles may cause some temporary localized pain, bruising, or light headaches. I understand that heat or cupping therapy may also be used and natural herbal formula may be prescribed. I accept the fact that there is no guarantee concerning the outcome of my acupuncture or herbal treatments and I understand that I may stop treatment at any time. I also accept that there are no refunds on any services, including herbal formula. I understand payment must be made in full at the time of service. Signature of Patient or Guardian: Date: 2 of 7

3 Medical History please check any following conditions you have had with X Allergies Asthma Bleeding tendency Cancer Diabetes Emphysema Epilepsy Glaucoma HIV Heart attack Hepatitis Hypertension Multiple Sclerosis Seizure Stroke Tuberculosis Other conditions not listed above, please explicit: Have you ever had any surgery? If yes, please list type and year below: Are you taking any medication currently? If yes, please list your medications: Are you taking any supplements currently? If yes, please list your supplements: Do you have allergy? If yes, please list your allergens: Do you have pacemaker installed? 3 of 7

4 Current Health Conditions Please check the following conditions that currently pertain to you with X, explicit if necessary. Sleep: good intermittent difficult falling asleep light sleep cannot sleep at all lots of dream feel rested upon waking up feel tired upon waking up Appetite: good; excessive fair Thirst: normal excessive poor no appetite at all picky eater no thirst thirsty but don't want to to drink comfort eating food craving (craving for ) Preferable temperature of drinks: room temperature icy Bowel movement: time(s)/day normal Consistency of stool: hard soft loose Urination: time(s)/day time(s)/night strong Urine color: light yellow medium yellow constipation diarrhea watery small pellets bloody weak incontinent painful dark yellow pink urgent abdominal cramping mucous no urine desire red Other info about urine: clear cloudy bubbles strong odor Perspiration: difficult normal easy spontaneous sweat night sweat flashes 4 of 7

5 Current Health Conditions Hands: swollen numb pain tingling discolored Feet: Body: swollen numb pain tingling discolored alternately cold and hot Energy: good fair Emotion: stressful irritable anxious Skin itchy flaky poor tired in the morning depressed panic sorrow painful inflamed acne tired in the afternoon happy worrisome sad rash hives ulcer Other symptoms and conditions: acid reflux dizziness abdominal pain ear ringing abdominal bloating heartburn chest pain chest congestion light headed cough nasal congestion nausea palpitation shortness of breath stomach pain vomiting conditions not listed above, please explicit: 5 of 7

6 Pain: Please mark the area that you are experiencing pain, and write down the pain level referring to the pain scale to the right. 6 of 7

7 For Women Only - Gynecological Conditions Check any following conditions currently applicable to you Endometriosis Peri-Menopause Blocked Fallopian tube Polycystic Ovarian Syndrome Infertility Pelvic Inflammatory Disease Menopause Recurrent miscarriages Ovarian cyst STD PMS Uterine fibroids Yeast infection Breast cancer Cervical cancer Ovarian cancer Uterine cancer Hysterectomy Menstruation regular irregular no menses How frequent is your menstrual cycle? How long does your menstrual cycle last? When was the 1st day of your last menses? Every days. days. Before menstrual cycle abdominal bloating abdominal cramping acne breakout breast tenderness On menstrual cycle abdominal bloating abdominal cramping breast tenderness diarrhea fatigue After menstrual cycle abdominal cramping breast tenderness dizzy craving for sweets depressed diarrhea fever moody insomnia lower back pain fatigue insomnia irritable insomnia lower back pain night sweat night sweat nosebleed swelling vomiting night sweat spotting During ovulation (usually 2 weeks before menstrual cycle) no ovulation moderate mucus abdominal pain excessive mucus bleeding clear mucus no/little mucus yellow mucus green mucus brown mucus 7 of 7

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