Shila Mathew MD., Medical Acupuncture

Name

E-mail

Your Family History

Has anyone in your family had (Mark all that applies):

Heart Disease	High Blood Pressure	Diabetes
Cancer	Other Diseases

Specify your relationship to that person(s)):

 

Your Medical History

Please check the appropriate symptom(s) if you have ever experienced it:

Head And Neck

Headaches	Hearing Problems	Ringing of the Ears
Vertigo	Dizziness	Eye Problems
Vision Problems	Nose Problems	Temporo mandibular Problems
Sinusitis	Cavities	Other Mouth Problems
Sore Throat	Neck Pain	Voice Changes

Other problems in these areas (specify):

 

Chest, Lung, Heart, And Skin

Chest Pain	Palpitations	Blood Pressure Problems
Tachycardia	Chest Oppression	Excessive Dreaming
Insomnia	Night Sweats	Excessive or Little Sweating
Lung Problems	Asthma	Shortness of Breath
Allergies	Skin Problems	Restlessness, Irritability

Other problems in these areas (specify):

 

Digestive System And Miscellaneous

Bleeding Gums	Belching	Nausea, Vomiting
Heart Burning	Poor Appetite	Loss of Taste
Bloating	Abdominal Pain	Bowel Movements After Meals
Sleepy After Meals	Gas, Rumbling	Diarrhea
Constipation	Hemorrhoids	Gaining or Losing Weight Easily
Bruising Easily	Heavy Legs	Varicosities

Other digestive problems (specify):

 

Gynecological System

Painful Periods	Heavy Periods	Irregular Periods
Long Periods	Absent Periods	Pre-Menstrual Syndrome (PMS)
Hot Flashes	Endometriosis	Painful Intercourse
Fertility Problems	Breast Problems	Miscarriages, Abortions

Other gynecological problems (specify):

 

Liver And Gall Bladder

Liver Problems	Sweaty Palms	Sweats Easily
Irritated Easily	Brittle Nails	Bitter Taste in Mouth
Muscle Cramps	Anxiety	Tension Headaches
Slow Digestion	Restlessness	Stiff Joints and Muscles

Other problems in these areas (specify):

 

Kidney, Urinary Tract, Endocrine System, And Various

Kidney Stones	Kidney Problems	Urinary Bladder Problems
Prostatitis	Frequent Urination	Urinary Tract Infections (UTI)
Incontinence	Low Sexual Drive	Erectile Dysfunction
Feeling Cold	Feeling Hot	Feeling Low Energy
Cold Hands	Cold Feet	Joint Pain
Weak or Sore Knees	Low Back Pain	Bone Problems

Other problems in these areas (specify):

 

Behavioral Health (Psychiatric Issues)

Depression

Anxiety

Schizophrenia

Other psychiatric issues (describe):

 

Previous Surgeries

Have you had any type of surgeries?

Heart	Uterus	Gall Bladder
Herniated Disc	Other

Describe the surgeries:

Other

Please mention any muscle/joint problem or any other problem anywhere else:

 

Important (Please mark all that apply from the list below) Are you pregnant? Yes No   Are you allergic to any medication? Yes No Describe Do you have any pace makers, metal plates or rods surgically implanted in your body? Yes No Describe Do you have any bleeding disorders like hemophilia? Yes No Describe Do you suffer from epilepsy? Yes No Describe

Any comments or items not covered here regarding your medical history that you feel the doctor should be aware of?