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Lam Clinic of Traditional Chinese Medicine

By Chris Morales,2014-09-25 11:55
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Lam Clinic of Traditional Chinese MedicineLam

Lam Clinic of Traditional Chinese Medicine

    2516 Broadway • Boulder, Colorado 80304 • 303.444.2357

Welcome to the Lam Clinic of Traditional Chinese Medicine. To help us provide you with the best possible

    care, please complete this form. This information will remain confidential.

Your Name: Date of Birth: / / Age:

o Male o Female Social Security Number:

Street Address: City: State: Zip:

Phone (day): Phone (evening):

    Occupation:

Email:

In case of emergency, contact:

    Name: Relationship: Phone:

    Street Address: City: State: Zip:

How did you hear about us?

Please describe your reason for today’s visit:

Have you ever had this difficulty or a similar one before? If yes, please explain:

Is it getting o better o worse or o staying about the same?

What seems to make it feel better?

What seems to make it feel worse?

Are you being treated elsewhere? o Yes o No

    By whom?

What was the diagnosis?

What were the results of treatment?

Are you currently taking prescription medicines, herbs, or supplements? o Yes o No

    If so, which ones?

    Personal Medical History Thyroid Disorders o Please check appliable boxes if you have had any of o Trauma (falls, accidents) these medical conditions: o Tuberculosis o Ulcers o Addiction (drugs or alcohol) o Other: ______________________ o AIDS/ARC _______________________________ o Allergies o Anemia o Appendicitis

     o Arteriosclerosis Family Medical History o Asthma Please check appliable boxes if anyone in your o Bleeding Tendency family has these conditions: o Blood Pressure (low) o Blood Pressure (high) o Alcoholism o Cancer o Allergies (list) o Chicken Pox ________________________________

    ________________________________ o Diabetes

    o Arteriosclerosis o Digestive Disorder

    o Asthma o Emotional Difficulties

    o Cancer o Emphysema

    o Diabetes o Epilepsy

    o Heart Disease o Fatigue

    o High Blood Pressure o Gout

    o Seizures o Headaches

    o Stroke o Heart Disease o Hepatitis o Herpes Please describe what you eat in a typical day: o HIV positive Breakfast: o Hypoglycemia

     o Injuries Lunch: o Insomnia o Intestinal Parasites o Measles Dinner: o Multiple Sclerosis

     o Mumps o Pacemaker Snacks: o Polio o Rheumatic Fever o Scarlet Fever Medications:

     o Sexually Transmitted Disease o Stroke Coffee: o Surgery (list) ________________ Cigarettes: _______________________________ Marijuana: _______________________________ Recreational drugs:

    Urinary Symptom Review

    Please put one check by a symptom you o Frequent o Nighttime o Cloudy sometimes experience; use two checks for o Difficult o Painful o Bleedingo Other those which often occur, and three checks for o Discharge

    symptoms that are a major concern.

     Throat

    Heart and Chest o Sore throat o Other o Headaches o Palpitations o Nervousness o Hoarseness o Dizziness o High blood pressure o Tremors o Difficulty swallowing o Memory loss o Tightness in chest

    o Convulsions o Other o Low blood pressure Skin

     o Rashes o Dryness Neurological o Moles or lumps that change o Numbness or tingling o Other o Nerve pain o Lumps that don’t change o Difficulty lying flat o Lack of coordination o Excessive sweating o Night sweating

     o Seldom sweat o Other Eyes

    o Blurred vision o Eyelid problem o Other Respiration

    o Floaters o Pain o Difficulty inhaling o Difficulty exhaling

     o Cough

    Circulation

    o Pain o Bruise easily o Bleed easily Digestion

    o Cold limbs, hands, or feet o Hot palms o Excessive appetite o Normal o Overall feeling of warmth o Low appetite o Other o Overall feeling of cold o Other o Always thirsty o Jaw problems

     o Never thirsty o Nausea

     o Stomach or abdominal pain Sleep

    o Insomnia o Drowsiness Bowel Movement o Excessive dreaming o Other o Diarrhea o Constipation

     o Rectal bleeding Ears o Colon problemso Bleeding o Hearing difficulty o Other o Pain

    o Earaches o Ringing (circle Low/High)

Nose

    o Sinus trouble o Congestion

Mouth

    o Gum problems o Dental problems

    o Unusual tastes o Tongue problems

Women Only Men Only

    Are you or might you be pregnant? Do you experience… o Yes o No o Maybe. o Reduced libido o Urinary frequency If yes, what month?__________ o Excessive libido o Impotence What method of birth control do you use? o Premature ejaculation o Genital discharge _____________________________________ o Seminal emission (spontaneous ejaculation

    Do you have regular PAP tests? o Yes o No. without sexual stimulation) How often?______________ o Pain associated with genitals Are you experiencing unusually low or high o Other:

    sexual desire? Other difficulties?

    Age at first menstruation:

    Age at menopause:

    Date of first day of last menstrual cycle:

    Number of days of last menstruation

    (bleeding):

    Usual length of monthly cycle (from first day

    of bleeding until day before next bleeding): Thank you for completing this form. If you

    Are your periods… need additional space to list health history,

    o Irregular: o Short o Long o Variable please use the space below. o Light blood o Thick blood o Watery blood

    o Heavy bleeding o Heavy clotting

    o Light bleeding o Stop and start again

    o Dark blood… o Red o Purple o Brown

    o Spotting… o Before o After o Mid-cycle

    o Painful:

    o Before o During o After o Mid-cycle

    Relieved by… o Heat o Cold o Pressure

     Do you have any pre-menstrual symptoms?

    o Painful or swollen breasts o Nausea

    o Irritability o Cramps or pain o Crying

    o Depression o Other:

    o Food cravings:

    Vaginal discharge

    o Normal o Bad odor o Watery o Itching

    o Thick o Dryness o Yellow o Other:

    o Clear or white

    Gynecological surgeries or problems (please

    describe)

    o Ovaries: o Vagina: o Uterus: o Breasts:

    o Fallopian Tubes: o Other:

    Pregnancies

    Total number:

    Complications:

    Number of children:

    Abortions or miscarriages:

    How long ago was your last pregnancy?

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