Shila Mathew MD., Medical Acupuncture

Contact Information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
Cell Phone
E-mail

Other Information

Date of Birth
	Month	Day	Year
Sex	Male	Female
Height
Weight
Occupation
Marital Status	Single	Married	Widowed	Divorced
Children?	No	Yes	How Many?
Smoking?	No	Yes	How many cigarettes/day?

Family Doctor:	Name Address Phone No:
Referring Doctor:	Name Address Phone No:

Your Condition

Please answer the following questions:

1. What are the main reasons you wish to see the Doctor?

Pain	Fatigue	Sleep Problems	Menstrual Problems
Other Problem		What?

2. How long you have been experiencing these problems?

3. Is this condition related to a workmen’s compensation claim? Yes  No

4. What kinds of treatments you had so far for your current problem? (select all that applies from below)

Medical	Chiropractic	Nerve Block
Surgery	Acupuncture	Acupressure
Other	Please specify

5. Are you currently taking any prescription, or over the counter medication or vitamins, or herbal supplements? No Yes

 If yes, List them here:


6. So far, which treatments have benefited you the most?

7. Please use the following drawings to mark the areas where you have pain:

8. Do you have any muscle or joint problems? Please describe.

9. Using a pain scale with 0=no pain, and 10=worst pain (you can use fractions like 2.5)
(0 = no pain) 0---1--- 2 ---3 ---4 ---5 ---6--- 7--- 8--- 9 ---10 (10 = worst pain)

What is your pain level today?

What is your pain level in general?

10. What do you expect from the Medical Acupuncture Treatment?

After completing the questionnaire, please click on the button marked "Submit Form." Thanks.