Admission Form. Dr. Na Zhai Clinic 1200 S. 5th Street Springfield, IL Please call for help:

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1 Admission Form Dr. Na Zhai Clinic 1200 S. 5th Street Springfield, IL Please call for help: Your privacy is important to us. The following form is intended to reduce the amount of paperwork needed to be done on your first visit in our office and give us more detailed information about you. Please print and fill this form, and bring it with your for your appointment. About you: Name: Birthday: / / Age: Marital: Address: City, State: Zip: Home Cell: Occupation In case of emergency contact: Name: Please circle: Male Female address: Your Physician Name Phone# Where does your physician work? Is your physician aware of your visit in this office Please circle: Yes / Health Insurance Insurance Company: Name of insured: ID #: Group #: Phone How did you hear about Dr. Na Zhai: Name: Or referred by

2 Your Present Illness In order to ensure your continued improvement it is essential to maintain full and open communication between the doctor and patient Don t be afraid to tell the doctor about issues in your life that could cause your health problems. You will be asked to write down and record your progress. These notes will be kept in your chart for later reference. While it is likely that you will feel better after your first visit, you may feel worse temporarily as your body begins to make changes. This too, can be a good sign that your body is beginning to respond to treatment. Please let the doctor know what your feelings are following each visit. Please tell us what symptoms bother you the most. Please list the most severe symptom first. First: Second: Third: Do you have any more medical issues that you would like to tell the doctor? Do you take any medications? If so, for what symptoms? Please note that you should not reduce or stop your medications without discussing it first with the physician who prescribed it for you.

3 Your Height: Your Medical History Your Weight: Do you generally feel: weakness, fatigue or fever ne of the Above Frequently catch cold? Yes Do you have or have you ever had headaches or dizziness?: Yes If yes, please explain: Any problems with your blood pressure? Any problems with your heart? How about your lungs and breathing? How is your digestion? How many times bowel movements do you have each day? Odorous? Diarrhea? Constipated?: Do you have any skin problems? Do you smoke? Yes If yes, how many cigarettes per day or have you tried to quit? Do you have or have you ever had a problem with alcohol? Yes Do you have or have you ever had a problem with drugs? Yes Have you ever been diagnosed with a mental illness?: Yes If yes, when and what was the diagnosis? Have you ever been hospitalized? Yes If yes, in which year? What problem? Have you ever had surgeries?: Yes If yes, please provide the year and the problem that needed surgery: Other major illnesses, major injuries, cancer, chemotherapy, radiation, please circle

4 Do you have any sensitivities or allergies to food or medication? Yes If yes, please list: Have you ever been diagnosed with a dental disease? Yes If yes, when and what type: Check the following that Most Accurately Describes Your Current Lifestyle: Sedentary lifestyle with little exercise Occasional Vigorous exercise Regular vigorous exercise Mild exercise in job,house or recreation Check Any Medications You Have Used Before: Anti-Acids Asthma Medications Digitalis Recreational Antibiotics Birth Control Thyroid Antidepressants Blood pressure Medications Insulin/Diabetes Meds Anti-Inflammatory Antihistamines Cortisone Laxatives Antineurotic Aspirin Decongestants Antipsychotic Other Medications: Menstrual History Do you have regular menstruation? Yes If no, please explain: Cramping during menstruation? Yes How many days of heavy bleeding during your menstruation? Date of your last menstruation: Number of miscarriages: Number of pregnancies: Hormonal Replacement Therapy: Birth Control Method if any: Family History How old is your father? How old is your mother? Please check the following conditions if any applies to them: Hypertension Coronary artery disease Stroke Diabetes Thyroid problems Renal disease Cancer Tuberculosis Asthma or other lung diseases Headache Seizure disorder Mental illness Suicide Addictions What motivated you to come to Dr. Na Clinic? Please circle below Major Illness Pain Detox Relax Anti-aging Medical check up

5 Your story regarding your health, please details Pleaser answer the following questions in your story below 1. What kinds of treatment have you tried? 2. Whom (Doctors, MDs) have you seen? His or her name and specialty? 3. Have you tried medications? What kind? Name of medications you have been on? Other medical procedures? 4. How do you feel prior to come in this clinic? Please note that payment is expected after your treatment. We encourage you to send your receipt to your insurance company. Dr. Na will respond to your insurance company s inquiry. Thank you Patient s signature: Date:

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