Patient Information Form ; Patient InformationAre you a first time patient?*YesNoIf you are a first time patient, we will ask a Family Medical History. If you are a current patient but your medical history has changed since your last visit, please choose "Yes" here.Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Have you had Herbal Medicine? Yes NoAre you under the care of a physician now? Yes NoFor what?*Other concurrent therapies?Pharmaceuticals taken in the past 2 months?Other supplements taken in the past 2 months?Issue #1Date Symptoms Began Date Format: MM slash DD slash YYYY Briefly Describe SymptomsHow did your symptoms begin?Average Pain IntensityNo Pain23456789Most PainLast 24 HoursAverage Pain IntensityNo Pain23456789Most PainLast WeekIs it getting worse? Yes NoDoes it bother you at.... Sleep Work OtherWhat seems to make it better?What seems to make it worse? I Have Another Medical IssueIssue #2Date Symptoms Began Date Format: MM slash DD slash YYYY Briefly Describe SymptomsHow did your symptoms begin?Average Pain IntensityNo Pain23456789Most PainLast 24 HoursAverage Pain IntensityNo Pain23456789Most PainLast WeekIs it getting worse? Yes NoDoes it bother you at.... Sleep Work OtherWhat seems to make it better?What seems to make it worse?Family Medical HistoryAllergies?Cancer?Additional Medical Issues Diabetes Heart Diseases High Blood Pressure Seizures Stroke AIDS/HIV Tuberculosis Measles Allergies Seizures Goiter Arteriosclerosis High Blood Pressure Chicken Pox Scarlet Fever Cancer Herpes Diabetes Alcoholism Mumps Epilepsy Ulcers Pleurisy Heart Disease Thyroid Disorder Whooping Cough Pneumonia Rheumatic Fever STD Surgery Multiple Sclerosis Emphysema Typhoid Fever Pacemaker Appendicitis Stroke Gout Polio Asthma Hepatitis Major Trauma OtherCheck any of the following conditions you currently have, or have had in the past. (Please also check if you feel any of the following are a significant part of your medical history).OtherPlease SpecifyLifestyleNot OftenOccasionallyModeratelySomewhat OftenFrequentlyAlcoholTobaccoMarijuanaOther DrugsStressOccupational HazardsHow often do you experience each of the following items?General SymptomsNot OftenOccasionallyModeratelySomewhat OftenFrequentlyPoor AppetiteBodily HeavinessChillsBleed or Bruise EasilyHeavy AppetiteHeavy SleepCold Hands & FeetNight SweatsSweat EasilyStrongly like cold drinksStrongly like hot drinksStrong Dreams / Disturbed SleepPoor CirculationFatigueShortness of breathMuscle crampsRecent weight loss / gainLack of strengthFeverVertigo or dizzinessParticular TasteHow often do you experience each of the following items?Particular Tastes*Pain ScaleNo pain23456789Extreme PainPlease describe the level of pain you are experiencing.Final QuestionsIn general, would you say your overall health right now is...PoorFairGoodVery GoodExcellentSignatureEmailThis field is for validation purposes and should be left unchanged.