New Asian Integrative Medicine Client Form
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Morocco
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Myanmar
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Netherlands
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Number of Children
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How did you hear about me?
Emergency Contact
Full Name
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Relationship
Physicians
Primary Physician
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Phone Number
Other specialist
First Name
Last Name
Type of treatment
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Your Health Concerns
Please identify your major health concern or why you are seeking treatment:
How long have you had this issue?
Have you been given a diagnosis for this issue?
Your Medical History
Please include childhood history.
Illnesses
Surgeries
Significant trauma
(Example: Physical: accidents, fractures, etc.; Emotional: trauma event, death of loved one)
Do you have a history of current or past infectious disease? Please describe.
Medications.
(Include all medications, herbs, supplements, over the counter drugs.)
Allergies/Sensitivities
(Please list any foods, drugs, medications or environmental factors which you are sensitive or allergic to)
General (Check all that apply)
Poor Appetite
Hearing Loss
Easy To Bleed or Bruise
Strong Thirst
Puffiness or Swelling
Night Sweats
Changes In Appetite
Weakness
Fevers
Sweat Easily
Poor Sleep or Insomnia
Poor Balance
Cravings
Sudden Energy Drops
Chills
Fatigue
Tremors
Weight Loss
Weight Gain
Emotional (check all that apply)
Anxiety
Depression
Irritability
Mood swings
Unexplained crying
Unexplained grief
Mania, or excess excitement
Skin & Hair (Check all that apply)
Rashes
Skin Ulcers
Hives
Itching
Eczema
Pimples
Dandruff
Hair Loss
Recent Moles
Head, eyes, ears, nose and throat. (Check all that apply.)
Dizziness
Cataracts
Taste/Smell Problems
Eye Strain/Pain
Nose Bleeds
Migraines
Recurring Sore Throat
Toothace
Ear Ringing
Headaches
Night Blindness
Facial Pain
Ear Aches
Lip or Tongue Sores
Blurry Vision
Sinus Problems
Concussions
Poor Hearing
TMJ Pain
Spot in Front of Eyes
Floaters
Cardiovascular
High Blood Pressure
Cold Hands
Cold Feet
Swelling Hands
Swelling Feet
Fainting
Irregular Heartbeat
Palpitations
Chest Pain
Lightheadness
Respiratory
Cough
Phlegm
Asthma
Bronchitis
Coughing Up Blood
Painful Breathing
Difficult Breathing
Pneumonia
Easily Winded
Gastro-Intestinal
Nausea
Bad Breath
Chronic Laxative Use
Indigestion
Blood in Stools
Constipation
Ulcers
Vomiting
Rectal Pain
Hemorrhoids
Diarrhea
Abdominal Pain
Intestinal Gas
Belching
Urology
Painful Urination
Decrease in Urine Flow
Cloudy Urine
Pain Groin Area
Urgency to Urinate
Frequent Urination
Kidney Stones
Sexually Transmitted Disease
Gynecology
Irregular Periods
Painful Periods
Breast Lumps
Spotting
Vaginal Discharge
Clots
PMS
Menopausal
Yeast Infections
Fertility Problems
Urinary Tract Infection
Age of First Menses
Duration of Menses
Date of Last Menses
Number of Pregnancies
Number of Births
Musculoskeletal
Arthritis
Muscle Spasms
Pain with Weather Changes
Muscle Weakness
Scoliosis
Pain with Activity
Muscle Cramping
Weak Joints
Pain After Waking
Cancellation Policy: Please respect the 48hour cancellation policy with a phone call to (415)758-2228. Text and/or email are not recommended. Clients who do not provide at least 48 hours notice will be subject to pay for the missed appointment. Missed appointments (no-shows) are billed the appointment fee. Your consideration and understanding are appreciated.
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