About You Your Name: Birth Day (mm:dd:yy): Marital Status: Address: Address line2: City: State: Zip: Email: Home Phone: Cell Phone: Employer: Work Phone: In Case Of Emergency Name: Phone: Relationship: Your Physician Name: Physician Phone: Health Insurance Insurance Company: Insurance Phone: Name of insured: ID #: Group #: Present Illness First Illness: Severity (0 to 10): How long have you been suffering from it?: Second Illness: Second Illness Severity (0 to 10) : How long have you been suffering from second illness?: Third Illness : Third Illness Severity (0 to 10): How long have you been suffering from third illness?: Do you have any more medical issues that you would like to tell the doctor?: Are you currently taking any medications? If so, for what symptoms?: Medical History Height: Weight: Do you generally feel weakness, fatigue or fever?: Frequent cold?: Do you have or have you ever had headaches or dizziness?: 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?: 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?: Do you have or have you ever had a problem with drugs?: Have you ever been diagnosed with a mental illness?: If yes, when and what was the diagnosis?: Have you ever been hospitalized?: If yes, please provide the date and specific problem: Have you ever had surgeries?: If yes, please provide the date and specific problem that needed surgery: Other major illnesses, major injuries, cancer, chemotherapy, radiation: Do you have any sensitivities or allergies to food or medication?: If yes, please list: Have you ever been diagnosed with a dental disease ?: If yes, when and what type: Check the Box that Most Accurately Describes Your Current Lifestyle: Check the Box that Describes Your Current Ambulatory Condition: Check Any Medications You Have Used Before: Other Medications: Menstrual History Do you have regular menstruation?: If no, please explain: Cramping during menstruation?: How many days of heavy bleeding during your menstruation?: Date of your last menstruation: Number of pregnancies: Number of miscarriages: Hormonal Replacement Therapy: Birth Control Method: Family History How old is your father?: How old is your mother?: Please check the following conditions if any applies to them: Other Information How did you hear about Dr. Na Zhai: Referred By (Name): What motivated you to come to Dr. Na Clinic?:
