Joseph Bonacci, M.S., L.Ac. Princeton Musculoskeletal InstituteHolistic Vision Acupuncture LLC 3131 Princeton PikeTel 609.896.9190 Bldg. 4, Suite 100Fax 609.896.3555 Lawrenceville, NJ 08648

PATIENT INFORMATION

NAME: __________________________________ ADDRESS: ________________________________________________

TELEPHONE: (Check your preferred contact number)

HOME: ______________________ WORK: _______________________ CELL:_______________________

EMAIL: ______________________________ OCCUPATION/SCHOOL:__________________________________________

SSN: __________________ BIRTHDAY: _____________ AGE:____ HEIGHT:____ WEIGHT:_____ GENDER:_______

MARITAL STATUS: SINGLE MARRIED LIFE PARTNER DIVORCED WIDOWED

DATE OF FIRST VISIT: ________________________ REFERRED BY: __________________________________

INSURANCE INFORMATION

MEDICARE INS#:___________________________________________________________________________

WORKER’S COMP: DATE OF ACCIDENT __________________ CLAIM#___________________________

MOTOR VEHICLE: DATE OF ACCIDENT ___________________ CLAIM#___________________________

POLICY SUBSCRIBER_________________ POLICY #________________ ADJUSTER NAME______________

----------------------------------------------------------------------------------------------------------------------------------------------------------

PRIMARY INSURANCE CO: _________________________________________________________

ADDRESS:___________________________________________________________

ID#:______________________________________ GROUP#:__________________________________________

NAME OF SUBSCRIBER: ____________________________ RELATIONSHIP: ______________________

SSN OF SUBSCRIBER: _____________________ DOB OF SUBSCRIBER: _______________________

----------------------------------------------------------------------------------------------------------------------------------------------------------

SECONDARY INSURANCE CO: _____________________________________________________

ADDRESS:___________________________________________________________

ID#:______________________________________ GROUP#:__________________________________________

NAME OF SUBSCRIBER: ____________________________ RELATIONSHIP: ______________________

SSN OF SUBSCRIBER: _____________________ DOB OF SUBSCRIBER: _______________________

ASSIGNMENT AND RELEASE OF INFORMATION STATEMENT- I certify that the information given by me is correct. I hereby authorize release of any information related to my medical care as requested by government agencies and/or insurance carriers. I hereby assign benefits to my provider and understand that in the absence of accepted insurance coverage, I/legal guardian am responsible for full payment of services rendered. This is also true if I do not have any insurance coverage.

________________________________________ ____________________ PATIENT OR GUARDIAN’S SIGNATURE DATE

1

CONTACTS

EMERGENCY CONTACT:____________________________ RELATIONSHIP:________________________TELEPHONE:_______________________________ ADDRESS:_____________________________________________

PHYSICIAN’S NAME: _______________________________TELEPHONE:_______________________________ ADDRESS:_____________________________________________

MAJOR COMPLAINT

1. _____________________________________________________________________________________________

2. _____________________________________________________________________________________________

3. _____________________________________________________________________________________________

When did you first notice this problem? ____________________________________________________________________

How long have you experienced this condition? ______________________________________________________________

What makes it better? What makes it worse? _________________________________________________________________

If you are experiencing pain, on a scale of 1-10, how would you rate it? ________________________________________

Have you tried the following therapies:

ACUPUNCTURE HERBAL MEDICINE PHYSICAL THERAPY MASSAGE CHIROPRACTIC

YOUR MEDICAL HISTORY

Allergies High Blood Pressure Diabetes Other (please specify) Hepatitis A/B/C/D High Cholesterol Heart Disease ___________________________________ Seizures Rheumatic Fever Birth Trauma ___________________________________ Significant Trauma Thyroid Disease Ulcers Date of last physical exam?_____________ Cancer Childhood Illness HIV/AIDS

FAMILY MEDICAL HISTORY (Select all that apply and specify which relative)

Cancer_________________________________________ Seizures_________________________________________ Rheumatic Fever_________________________________ Hepatitis________________________________________ Heart Disease____________________________________ Diabetes_________________________________________ Tuberculosis_____________________________________ Emotional Disorder________________________________ High Blood Pressure_______________________________ Other conditions:__________________________________

________________________________________________

MEDICATION, ALLERGIES, AND PAST HOSPITALIZATION

What medications, supplements or herbs are you currently taking?______________________________________________________________________________________________________________________________________________________Allergies? (foods, drugs, etc.) No Yes (please specify):______________________________________________________Have a cardiac pacemaker? No YesHospitalized in the past year? No Yes (please specify why): __________________________________________________Had any major surgeries? No Yes (list when and why): ______________________________________________________

2

DIET AND LIFESTYLE (Select all that apply and indicate frequency) Coffee____________________________________ Alcohol_____________________________________ Black Tea__________________________________ Tobacco_____________________________________ Caffeinated beverages________________________ Recreational drugs_____________________________ Soda/soft drinks_____________________________ Exercise_____________________________________ Water_____________________________________ Time spent outdoors____________________________

Which of the following foods are part of your regular diet? Eggs Beans Fresh Fruit Yogurt Cereal Red Meat Nuts Dark Leafy Greens Milk Chips Fish Tofu Other Vegetables Cheese Candy Chicken Whole Grains Pizza Butter Chocolate Pork/Bacon Potatoes Fast food/Take-out Non-dairy Milk Ice Cream Cold cuts Bread/Bagels Other (please list):_______________________________________________

What types of tastes do you crave? Salty Sweet Fried/greasy Fatty Sour SpicyWhat triggers your cravings? Stress Depression Boredom Menses Other (specify): ___________________When do you notice your cravings most?_________________________________________________________________Stress Level (rank 1-10)_______________ Do you sleep well? Yes No How many hours? ________ Do you wake up at night?___________Why?_________________________________________________________________________________________

GENERAL HEALTH

Poor appetite Poor balance Fever Large appetite Poor coordination Sweat Easily Strong thirst Night sweats Fatigue Food cravings Disturbed sleep Sudden energy drop Weight loss Insomnia Anemia Weight gain Bruise/bleed easily Other (please specify):______________________ Cold hands and feet Catch colds easily ________________________________________ Tremors Chills

SKIN AND HAIR

Rashes Hair loss Neurodermatitis Ulcerations Recent moles Warts Psoriasis Dandruff Shingles Acne Excema Other (please specify):_______________________ Itching Hives _________________________________________ Redness Dry skin/hair

CARDIOVASCULAR

Palpatations Poor circulation Blood clots Irregular heartbeat High Blood Pressure Other: (please specify):_______________________ Coronary Heart Disease Low Blood Pressure _________________________________________ Chest pain/tightness Swelling of hands/feet

3

HEAD, EYES, EARS, NOSE & THROAT

Dizziness Night Blindness Change in smell Headaches Dry eyes or redness Sore throat Migraines Glaucoma Hoarseness Facial pain or numbness Cataracts Difficulty swallowing Trigeminal Neuralgia Tinnitus Change in Taste Bells’ Palsy Decreased hearing Oral ulcers TMJ or jaw clicking Ear infection Toothache Eye Floaters Nosebleeds Bleeding gums Eye Pain Sinusitis Other: (please specify):_______________________ Blurred Vision Hay fever/allergies _________________________________________

RESPIRATORY

Chronic cough Difficulty breathing Frequent/chronic colds Coughing blood Difficulty breathing when lying down Bronchitis Coughing phlegm Flu Other: (please specify):_________________ Nasal congestion Pneumonia ___________________________________ Shortness of breath Asthma

GASTROINTESTINAL

Nausea Chronic gastritis Hemorrhoids Vomiting Ulcers Bad breath Diarrhea Indigestion Frequent laxative use Constipation Heartburn/Acid reflux Gallstone Gas Lack of appetite Jaundice Bloating Excessive hunger Cirrhosis Belching Rectal pain Other: (please specify):_________________ Abdominal pain/cramps Bloody/black stools ___________________________________

UROGENTIAL

Frequent urination Waking at night to urinate Kidney stones Painful urination Incontinence Genital sores Urgent urination Bladder infection Other: (please specify):_________________ Decrease in urine flow Blood in urine ___________________________________ Increase in urine flow Impotence

MUSCULOSKELETAL

Neck pain Finger pain Chronic lumbar muscle strain Back pain Leg cramps Sprained ankle Knee pain Rib pain Sciatica Foot/ankle pain Cervical spondylopathy Muscle weakness Shoulder pain Carpal tunnel syndrome Scoliosis Hip pain Tennis Elbow Other joint/bone problems (specify):______ Hand/wrist pain Acute lumbar sprain ___________________________________

NEUROPSYCHOLOGICAL

Seizures Concussion Insomnia4

Epilpsy Depression Stroke/TIA Dizziness Anxiety Hemiplegia Loss of balance Bad temper Alcoholism Numbness Stress Schizophrenia Poor memory Attempted Suicide Other (please specify):_________________ Lack of coordination History of psychiatric treatment ____________________________________

METABOLISM, ENDOCRINE, AND IMMUNE

Diabetes Arthritis Chronic Fatigue Syndrome Gout Rheumatic arthritis High cholesterol Hyperthyroidism Lupus Simple obesity Hypothyroidism Fibromyalgia Other (please specify):_________________

____________________________________

MALE REPRODUCTIVE SYSTEM / GENITALIA

Pain/itching of genitalia Lumps in testicles Enlarged prostate Genital lesions/discharge Impotence Other (please specify):_________________

____________________________________

FEMALE REPRODUCTIVE SYSTEM/ GYNOCOLOGICAL

Painful Menses Pelvic Inflammatory Disease Hot flashes No Menses Abnormal pap smear Decreased sex drive Scanty menstrual flow Fibroids Vulvodynia Irregular menses Breast lumps/swelling Vomiting during pregnancy Premenstrual syndrom Endometriosis Infertility Menstrual odor Ovarian Cysts Polycystic Ovarian Syndrome Vaginal discharge STD Yeast infections Vaginal dryness Urinary Tract Infection Other: (please specify):_________________

___________________________________

Age at first Period?_______ Age at Menopause?________ No. Days period flow?_______ Length of Cycle?_________Color: Brown Dark Red Light red/pink Bright red Quantity: Heavy Moderate LightClots: Large Small NonePMS Symptoms: ________________________________________________________________________________No. of pregnancies: _______ No. of live births: _______ No. of miscarriages: _______ No. of abortions: _______Currently trying to conceive? Yes No Contraception (if any):______________________________________________Pertinent Pregnancy History: ______________________________________________________________________________

*Please fill out the General Pain Index Questionnaire on the next page if the condition for which you seek treatment involves pain*

GENERAL PAIN INDEX QUESTIONNAIRE

We would like to know how much your pain presently prevents you from doing what you would normally do. Regarding each category, please indicate the overall impact your present pain has on your life, not just when the pain

5

is at its worst.

Please circle the number which best describes how your typical level of pain affects these six categories of activities

1. FAMILY / AT-HOME RESPONSIBILITIES SUCH AS YARD WORK, CHORES AROUND THE HOUSE OR DRIVING THE KIDS TO SCHOOL

0 1 2 3 4 5 6 7 8 9 10 COMPLETELY ABLE TOTALLY UNABLE

TO FUNCTION TO FUNCTION

2. RECREATION INCLUDING HOBBIES, SPORTS OR OTHER LEISURE ACTIVITES

0 1 2 3 4 5 6 7 8 9 10 COMPLETELY ABLE TOTALLY UNABLE

TO FUNCTION TO FUNCTION

3. SOCIAL ACTIVITIES INCLUDING PARTIES, THEATER, CONCERTS, DINING-OUT AND ATTENDING OTHER SOCIAL FUNCTIONS

0 1 2 3 4 5 6 7 8 9 10 COMPLETELY ABLE TOTALLY UNABLE

TO FUNCTION TO FUNCTION

4. EMPLOYMENTINCLUDING VOLUNTEER WORK AND HOMEMAKING TASKS

0 1 2 3 4 5 6 7 8 9 10 COMPLETELY ABLE TOTALLY UNABLE

TO FUNCTION TO FUNCTION

5. SELF-CARESUCH AS TAKING A SHOWER, DRIVING, OR GETTING DRESSED

0 1 2 3 4 5 6 7 8 9 10 COMPLETELY ABLE TOTALLY UNABLE

TO FUNCTION TO FUNCTION

6. LIFE-SUPPORT ACTIVITIESSUCH AS EATING AND SLEEPING

0 1 2 3 4 5 6 7 8 9 10 COMPLETELY ABLE TOTALLY UNABLE

TO FUNCTION TO FUNCTION

PATIENT NAME________________________________________________ DATE________________________

SCORE _________ [60]

6