PATIENT INFORMATION PATIENT INFORMATION INSURANCE
Who is responsible for this account?___________________
Relationship to Patient________________________
Is patient covered by additional insurance?
Relationship to Patient________________________
ASSIGNMENT AND RELEASE
I, the undersigned, certify that I(or my dependent) have insurance
coverage with ________________________and assign directly to
__________________________all insurance benefits, if any,
otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by
insurance. I hereby authorize the provider to release all
information necessary to secure the payment of benefits. I
authorize the use of this signature on all insurance submissions.
PHONE NUMBERS ACCIDENT INFORMATION
Best time & place to reach you__________________
IN CASE OF EMERGENCY, CONTACT
To whom have you made a report of your accident?
Attorney Name (if applicable)_____________________
Home phone____________Work phone__________
GENERAL INFORMATION Have you had acupuncture before?
Are you currently under the care of a physician?
No If Yes, for what?___________________________
ORIENTAL MEDICINE INTAKE FORM
Name:______________________________________ Date:_______________________ PRESENT HEALTH CONCERNS: Please list your most important health concerns in order of their significance. 1. ________________________________________ Approx. Date of Onset:____________________________ Does it interfere with your:
2. ________________________________________ Approx. Date of Onset:____________________________ Does it interfere with your:
3. ________________________________________ Approx. Date of Onset:____________________________ Does it interfere with your:
Please list all medications that you are currently taking (or have used in the past two months), with dosages: 1.________________________________________
Please list any vitamins, minerals, herbs, or homeopathic remedies that you are presently taking: 1.________________________________________
Please list allergies that you have to any of the following: Drugs:_________________________________ Foods:_______________________________________________ Other (i.e. pollen, paint, etc.):____________________________________________________________________ HEALTH HISTORY Past Medical History: Please list past injuries, broken bones, surgeries and hospitalizations, with approx. dates. ___________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Personal Habits: Work Activity: Exercise:
Do you follow any diet regimens/restrictions?
If Yes, describe:_____________________________
Do you have children?
No If Yes, how many?__________Ages______________________
Are you, or could you be currently pregnant?
Please check if you have had (in the last three months) GENERAL Poor appetite
Other hair or skin concerns: HEAD, EYES, EARS, NOSE, AND THROAT Concussions
Headaches (location, triggers, severity)? Other head & neck concerns: CARDIOVASCULAR High blood pressure
Other heart or blood vessel concerns: RESPIRATORY Cough
Production of phlegm - color?________
Pneumonia Other lung related concerns:
History of chronic laxative use? Other concerns with your general digestion: GENTIO-URINARY Pain on urination
If you wake to urinate, how often? Other concerns with genitals or urinary system: MUSCULOSKELETAL Neck pain
Other muscle, joint or bone concerns: NEUROPSYCHOLOGICAL Seizures
Have you ever been treated for emotional problems? Have you ever considered or attempted suicide? Other neurological or psychological concerns: GYNECOLOGY Age of first menses______ If no longer menstruating, approximate date ceased____________
First day of last menses______ Length between menses:______days Duration of period:_____days Unusual flow (
GYNECOLOGY (continued) Changes in body or psyche prior to menstruation (“PMS”): Date of last PAP:________________ Results were:
If you use birth control, what type & for how long? Have you ever used hormonal methods for contraception or period regulation? (i.e. the pill, Depo-Provera, etc.) Other gynecological concerns: PREGNANCY HISTORY Number of pregnancies______
Were your births relatively normal? Explain: Other related concerns: COMMENTS Please let us know of any other concerns you would like to address: Family History: Please fill in the boxes for each condition that applies to one of your family members. Comments
Evaluation of New Bactericides for Control of Fire Blight of DESCRIPTION: Pears Caused by Erwinia amylovora PROJECT LEADER: Jim Adaskaveg - UC Riverside and Doug Gubler - UC Davis 2002 FUNDING: $7,000 FUNDING SOURCE: California Pear Advisory Board 'XCNWCVKQP QH PGY DCEVGTKEKFGU HQT EQPVTQN QH HKTG DNKIJV QH RGCTU ECWUGF D[James E. Adaskaveg and Doug Gubler, Department of Plant
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