Chinese Medicine Center
New Health Chinese Medicine Center
Phone & FAX 215-488-7896 Cell 609-751-1868
INFORMAITON REQUIRED FOR CASE HISTORY
CHART NUMBER_________________________ DATE___________________________________________
PATIENT NAME___________________________________________________________Sex_____________
(Mr./Mrs./Miss) First Name Middle Initial Last Name
DOB _____________Age _____Occupation _________________________________________SSN #________________
Home Address_______________________________________________________________________________________
Home Phone ____________________Cellular Phone ______________________Business Phone_____________________
Guardian Name for Underage__________________________________________________________________
Please answer each question
History of Present Illness
Chief Complaint: ____________________________________________________________________________ __________________________________________________________________________________________
|What medicine, if any, are you taking now? |YES □ NO □ |
|____________________________________________________________ | |
|____________________________________________________________ | |
|Are you pregnant now? |YES □ NO □ |
|Feeling—Anxiety, Depression or Hallucination? |YES □ NO □ |
Past Medical History
|Are you now or have you been under the care of a physician during the past two years? |YES □ NO □ |
|Are you subject to profuse bleeding? |YES □ NO □ |
|Are you subject to any nervous disorder, fainting or dizziness? |YES □ NO □ |
|Are you sensitive or allergic to any drug? |YES □ NO □ |
|If yes, specify the medicine? _____________________________________ | |
|Have you had heart trouble or high blood pressure? |YES □ NO □ |
|Have you had rheumatics fever? |YES □ NO □ |
|Have you had diabetes? |YES □ NO □ |
|Have you had asthma? |YES □ NO □ |
|Have you had tuberculosis? |YES □ NO □ |
|Have you had kidney, liver gallbladder, or stomach problem? |YES □ NO □ |
|Have you experienced any unfavorable reaction from any previous medical treatment? |YES □ NO □ |
|If yes, please provide detail? _____________________________________ | |
Family History
Medical history of other family members___________________________________________________________
Permission is hereby granted for necessary Acupuncture and Herbs treatment.
Patient (Guardian) Signature_________________________ Date ______________
Note
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