Microsoft word - initialintakeform

Welcome to our clinic. Please help up provide you with the best care by taking time to complete this evaluation questionnaire. All answers will be held absolutely CONFIDENTIAL. If you have any questions please feel free to ask. If there is anything you wish to bring to our attention which is not asked in this form please use the ‘Comments’ section. Thank you. Personal Information
Name______________________________________________________ Date___________________________ Home Address _______________________________________________________________________________ City______________________________________________ State__________________ Zip______________ Home Phone_________________________________ Work Phone____________________________________ Cell Phone ___________________________ E-mail _______________________________________________ Occupation______________________ Family Physician ____________________________________________ In Emergency Notify_________________________ Phone___________________ Relationship ______________ Who should we thank for referring you to this office? ________________________________________________ Sex: □ Male □ Female Height_______ Weight_______ Birth date__________ Age____
Marital Status: Married___ Single___ Divorced___ Widowed___ Number of children____
Have you received acupuncture therapy before? □ Yes □ No When?______With whom?_______
Past Medical history/Family History

Cancer ____ ____ ________ Diabetes ____ ____ ________
Hepatitis ____ ____ ________ Heart Disease ____ ____ ________
High blood pressure ____ ____ ________ Seizures ____ ____ ________
Rheumatic Fever ____ ____ ________ Emotional Disorders ____ ____ ________
Infectious Disease ____ ____ ________ Tuberculosis ____ ____ ________
Sexually Transmitted Diseases: □ Gonorrhea □ Syphilis □ AIDS □ HPV □ Chlamydia □ Herpes Date _______________
Other relevant medical history (please include dates)
List any medications and/or supplements you are currently taking (continue on the back if necessary)
Medicine and Dosage

Check the appropriate box if any of the following statements are true:

□ I am taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs)
Please indicate the use and frequency of the following:

What is/are the main health problem(s) for which you are seeking treatment?
To what extend does this problem affect your daily activities (work, sleep, eating, etc.)?_______________
How long has it been since you first noticed any symptoms? ____________________________________
Have you been given a diagnosis for this problem by a family physician? __________________________
If so, what is it?__________________________________________________________________ What other forms of treatment have you sought?
List any allergies, food sensitivities or food cravings that you have.
List any accidents, surgeries, or hospitalizations (include date).
Occupational stress factors (physical, psychological, chemical): ___________________________________
Lab Results (please include copies)
How do you feel about the following areas of your life? (please check the appropriate spaces and indicate
any problems you may be experiencing)

Your Comments (use back if necessary): ___________________________________________________________
For Women

Age of first period (menarche)________ Are you pregnant? □ Yes □ No # of pregnancies _____ # of live births____
Age of last period (menopause)_______
# of abortions _____ # of miscarriages ____ Number of days between periods______ Date of last: Gynecologic exam _____________ Pap smear ____________ Number of days of flow_____________ Mammogram________________ Bone Density scan ____________________ Results _________________________________________________________ Color of flow: _______ Spotting? □ Yes □ No Average number of pads you use per day: 1st day____ 2nd day____ 3rd day____ 4th day_____ + days_____ Have you been diagnosed with: □ Fibroids □ Fibrocystic Breasts □ Endometriosis □ Ovarian cysts PID____
Location of pain: Lower abdomen___ Lower back___ Thighs___ Other__________
Nature of pain (please indicate before, during or after menses):
Other symptoms related to menses:
□ Swollen Breasts □ Mood swings □ Ravenous appetite Bloating □yes □no □ Poor appetite □ Hot flashes □ Night sweats Bearing down sensation __________________________ □ Increased libido □ Decreased libido □ Insomnia
For Men
Date of last prostate check up __________ PSA results___________ Manual prostate exam results_______________________
Lab Results: _____________________________________________________________________________________________
Frequency of Urination: daytime _____ Nighttime______ Color of urine: □ clear □ murky Odor: ________________________
Symptoms related to prostate:
□ Erectile Dysfunction □ Increased Libido
Pain chart
please mark painful or areas of distress on the chart below (use words if necessary)
. Symptom Survey

The following is a list of symptoms that you have experienced within the last three months. Indicate the length of time you have had
this condition.
Please indicate as follows: blank = never experience check mark (√) = sometimes experience plus sign (+) = frequently experience

□ Insomnia: __ Difficulty going to sleep __ Difficulty waking up __ Difficulty staying asleep
□ Emotional state: __ Happy __ Sad __Angry __Depressed __Over thinker __Lethargic
□ Circulatory Problems: __Cold Hands __Cold Feet __Both __Other: Describe_________________________________________
□ Palpitations: How often _____________ Under what conditions ___________________________________________________
□ Appetite: __Increased __Decreased __Easily Hungered __No Appetite
□ Bloating
□ Gas
□ Acid Reflux
□ Indigestion
□ Diarrhea
□ Constipation
□ Abdominal aches/pains
□ Respiratory problems
□ Cough: __Dry __Wet __Cough up Phlegm
□ Shortness of Breath: __Slight Exertion __All the time
□ Asthma: __Mild __Intermittent __Chronic When were you diagnosed______________________________________________
□ Stifling sensation in chest
□ Allergies
□ Sinus Problems
□ Easily catch cold
□ Urination problem Describe__________________________________________________________________________________
□ Painful Urination
□ Night urination
□ Easily Agitated
□ Difficulty Making Decisions
□ Headaches: How often _______________ Location______________________________________________________________
□ Bitter Taste in mouth
□ Dry Eyes
□ Brittle Nails
□ Stiff Joints
In general, do you feel more ____Hot or more ____Cold
Are you thirsty ____No ____Yes
How many hours do you sleep per night _____________________
How is your overall energy level______________________________________________________________________________
Any recent changes in vision ___No ____Yes
Do you see floaters in your vision ___No ___Yes
Any recent changes in your hearing ___No ____Yes Please Describe
_______________________________________________________ Any other abnormal conditions that you have noticed in your general sense of health _____________________________________



J. Glenn Morris, Jr. Cholera has affected humans for at least a millennium We are currently in the throes of the seventh pandemic and persists as a major cause of illness and death worldwide, (caused by V. cholerae of the El Tor biotype), which with recent epidemics in Zimbabwe (2008–2009) and Haiti originated almost 50 years ago in the Celebes. In contrast (2010). Clinically, evidence


CURRICULUM VITAE ! JOSE M. DI DIEGO ! EDUCATION Buenos Aires University, Argentina Degree: M.D. POSITIONS HELD Research Fellow, Favaloro Foundation, Bs As, Argentina. Postdoctoral Fellow, MMRL, Utica, NY, USA. Research Scientist, MMRL, Utica, NY, USA. Program and Laboratory Manager, Experimental Cardiology Department, MMRL, Utica, NY, USA. ! ACADEMIC AND PROFESSIONAL HONORS

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