New Patient Health History Questionnaire

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Name:. Dear Nov Patient: a) Please read and fill in all of the information that pertains to you. b) On pages 2 through 11, under each category, check all symptoms that you experience either acutely or chronically. c) Add and total all of the boxes you check. d) today's date. Physical Test Test Results Cholesterol Prostate Mamography Pap Smear Blood (which test?) HIV/STD Other Diabetes Heart Disease Asthma High Blood Pressure Syphilis Meningitis Epilepsey Paralysis Glaucoma Please indicate if you have (or have been tested for) any of the following Allergies CVA (stroke) Pneumonia Gonnorhea Measles HIV High Fever Cancer Mumps Rheumatic Fever Thyroid Disorder Emphysema Bleeding Tendency Nervous Disorder Monoucleosis Multiple Sclerosis Jaundice Hepatitis Vein Condition Tuberculosis Chicken Pox Polio Migraines Other Liver Illnesses Other Heart illnesses Other Kidney Illnesses Other Lung Illnesses Immunizations? Surgeries?

1. Pain On the figures below, please mark clearly any areas of pain and indicate any scars. What makse the pain better? Soft Pressure Hard Pressure Cold Hot Exercise Rest Other What makes the pain worse? Soft Pressure Hard Pressure Cold Hot Exercise Rest Other 2. Describe Your Pain Sharp Fixed Burning Moving Cramping Aching Dull Other: LONGER pertain to you, or if you HAVE NOT experienced the symptoms for two weeks. Add up : : : : : :

5. Liver, Spleen, Heart Function LONGER pertain to you, or if you HAVE NOT experienced the symptoms for two weeks. Add up Dizziness See floating black spots : : : : : : 6. Heart Anxiety Sores on tip of tongue Restlessness Mental confusion Chest pain traveling to shoulder Frequent dreams Wake unrefreshed Coffee? How much per week? _ LONGER pertain to vou, or if you HAVE NOT experienced the symptoms for two weeks. Add up ( J ^ j _ : : : : : : 7. Spleen Function Low Appetite Abrupt Weight Gain Abrupt Weight Loss Abdominal Bloating Abdominal Gas (Continued...) LONGER pertain to you, or if you HAVE NOT experienced the symptoms for two weeks. Add up

3. Kidney Function (Overall Temperature) Cold hands Cold Fingers Cold Toes Cold Feet Sweaty Hands Sweaty Feet Hot Body Temperature Sensation Cold Body Temperature Sensaton Afternoon Flushes Night Sweats Heat in the hands, feet & chest Hot flashes any time of the day Thirsty Perspire easily Lack of perspiration Do you take water to bed FOR LONG TERM PATIENTS ONLY: On the day of your re-exam only check the boxes that NO LONGER pertain to you, or if you HAVE NOT experienced the symptoms for two weeks. Add up : : : : : : 4. Lung, Kidney Function (Overall Energy) FOR LONG TERM PATIENTS ONLY: On the day of your re-exam only check the boxes that NO LONGER pertain to vou. or if you HAVE NOT experienced the symptoms for two weeks. Add up vour boxes and enter current date. Shortness of breath Difficulty keeping eyes open (daytime) General Weakness Easily catch colds Low Energy Feel worse after exercise Chronic (daily) fatigue & malaise : : : : : :

7. Spleen Function.. Cont'd Gurgling noise in stomach Fatigue after eating Prolapsed Organs? Which? Bruise easily? Over-Thinking Worry ~ : : : : : : 8. Lung Function _ LONGER pertain to vou. or if vou HAVE NOT experienced the symptoms for two weeks. Add up Nasal discharge (color) Cough Nose Bleeds Sinus Congestion Dry Mouth Dry Nose Dry Skin Allergies (what? Alternating Chills/Fever Sneezing Heartache (location Overall achy feeling in body Stiff Neck Stiff Shoulders Sore Throat Difficultybreathing Smoke cigarettes (# per day Saddness Melancholy ~ j ^ : : : : : :

9. Spleen, Stomach, Small / Large intestine Function LONGER pertain to you, or if vou HAVE NOT experienced the symptoms for two weeks. Add up Loose Stools Constipated Incomplete Stools Diarrhea Blood in Stools Mucous in Stools Undigested food in the stools ~ \ ^ ~~ : : : : : : 10. Stomach Function Burning sensation after eating Large appetite Bad Breath Canker Sores (mouth) Bleeding, swollen or painful gums Heartburn Acid Regurgitation Ulcer (diagnosed?) Belching Hiccoughs Stomach Pain Vomiting LONGER pertain to vou. or if vou HAVE NOT experienced the svmptoms for two weeks. Add up ~ "J! ^ : : : : : : -»?

11. Dampness Trapped in the Body Bodily sensation of heaviness Mental heaviness Mental sluggishness Mental fogginess Swollen hands Swollen feet Swollen joints Chest congestion Nausea Snoring LONGER pertain to vou, or if vou HAVE NOT experienced the symptoms for two weeks. Add up : : : : : : 12. Liver Function ( Eyes ) Itchy Bloodshot Hot Dry Watery Gritty Blurry Vision Decreased Night Vision Near-sighted Far-sighted LONGER pertain to vou, or if vou HAVE NOT experienced the svmptoms for two weeks. Add up : : : : : :

13. Liver, Gall Bladder Function LONGER pertain to you, or ifyou HAVE NOT experienced the symptoms for two weeks. Add up your boxes and enter current date. Alternating Diarrhea & Constipation Chest Pain Tight sensaton in the Chest Bitter taste n the mouth Anger easily Depression Frustraton Irritability Skin Rashes Headache at the top of the head Tingling Sensation Re-Exam 1 Re-Exam 2 Re-Exam 3 Re-Exam 4 Re-Exam 5 Re-Exam 6 Numbness Muscle twitching Muscle cramping Muscle spasms Seizures Convulsions Lump in the throat Neck tension Shoulder tension Limited Range-of-Motion (Neck) Limited Range-of-Motion (Shoulder) How much Alcohol / day? Recreatonal drugs? (which? High-pitched ringing in ears Gall Stones (history or current) STD's (which? Unable to adept to Stress : : : : : :

14. Kidney, Urinary Bladder Function Frequent cavities, teeth problems Easily broken bones Sore knees Weak knees Cold sensaton in the knees Low back pain Memory problems Excessive hair loss Low-pitched ringing in the ears Kidney Stones Bladder infectons Lack of bladder control Wake during the night 2 (or more) times to urinate Fear Easily startled LONGER pertain to vou, or if vou HAVE NOT experienced the symptoms for two weeks. Add up vour boxes and enter current date. ~ j [" Hlotal : : : : : : 15. Libido _ LONGER pertain to vou, or if vou HAVE NOT experienced the symptoms for two weeks. Add ud vour boxes and enter current date. Normal High Low ~ ~ : : : : : :

16. Urination ( Bladder Function ) NEW PATIENT HEALTH HISTORY QUESTIONNAIRE LONGER pertain to you, or if you HAVE NOT experienced the symptoms for two weeks. Add up (Color - (please check) Pale Dark yellow Clear Re-Exam 1 Re-Exam 2 Re-Exam 3 Re-Exam 4 Re-Exam 5 Re-Exam 6 Reddish Cloudy Scanty Profuse Strong Odor Burning Painful Discharge Difficult Urgent Frequent : : : : : : Yes Yes Yes Yes No No No No WOMEN ONLY Do you have a regular menstrual cycle? Are you prgnant? Do you have bleeding between periods? Do you have a vaginal discharge? Age of first menstruation Average number of days in flow Average number of days in entire cycle Number of children Number of pregancies Age of men Dpause (if applicable) Please fill in the Menstrual chart: Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Color (chose one): normal, pale, bright red, brown rust, dark purple, other Amount of flow (chose one): normal, heavy, light Pain/Cramps (chose one): dull, sharp, other Vomiting (check if yes): Nausea (check if yes): Please fill in the Menstrual chart: Day 1 Day 2 Day 3 Day 4 Day 5 Day S Day 7 Color (chose one): normal, pale, bright red, brown rust, dark purple, other Amount of flow (chose one): normal, heavy, light Pain/Cramps (chose one): dull, sharp, other Vomiting (check if yes): Nausea (check if yes):

Women Only: Nausea Vomiting Food cravings Water retention Breast swelling Breast tenderness Headaches Migraines Dull pain (where? _ Sharp pain (whre? Deprsesion Irritabiity Anxiety Infertility Other (explain: _ LONGER pertain to vou, or if vou HAVE NOT experienced the symptoms for two weeks. Add up : : : : : : - a-,?

Men Only: Swollen testes Testicular pain Impotence Premature ejaculaton Feeling of colenss or numbness in external genitalia Difficulty with erection Thick or dense semen High sex drive Low sex drive Discolored or yellow semen Nocturnal emissions Fatigue after sex Pain in penis Pain in testes Infertility Other (explain: FOR LONG TERM PATIENTS ONLY: On the day of your re-exam only check the boxes that NO LONGER pertain to vou, or if vou HAVE NOT experienced the symptoms for two weeks. Addup vour boxes and enter current date. Re-Exa m 1 Re-Exa m 2 Re-Exa m 3 Re-Exa m 4 Re-Exa m 5 Re-Exam 6 : : : : : : Acupuncture Wellness / RW Clinic»2820 Camino Del Rio South, Suite 104, San Diego, CA 92108* 619-265-0291 (Page 12)

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