286>756<6<29

This is a
CONFIDENTIAL questionnaire to help us determine the best treatment plan for you.
______________________ ____
Acupuncture _____________________ _____
Previous Acupuncture? Yes No When? ____/____/_______ With Whom? ________________
Please indicate the use and frequency of the following:
Yes No Amount
Yes No Amount Yes No Amount
Tobacco " _______ Water ________
Alcohol _______ Soda ________
Please Check the Box if any of the following statements are true:
I have known allergies: Yes No I am taking Coumadin/ Warfarin/ Plavix: Yes NoI have a pace-maker: Yes No I am taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs) Yes NoI have a history of fainting or seizures Yes No
Physician History
Have you seen a physician in the last year? Yes No If yes:Physician’s Name: _________________________________ Phone: ________________________Approximate date of most recent examination/visit? _____________________________________
What is your Chief health Complaint?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Do you have any additional health concerns?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Medications:
Please list any prescription or OTC medications or supplements and herbs you are currently taking:
Rx/Supplement/Herbs
Reason for
Prescribed by?
Date of last
taking the item? long?
check up?
List any allergies, food sensitivities you have.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
List any accidents, surgeries or Hospitalizations (include date).
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
How do you FEEL about the following areas of your life?
Please check the appropriate boxes and indicate any problems you may be experiencing.
______________________________________For Women______________________________________
# of Pregnancies ________ Age of Last Period (menopause) ________ # of live births ______ # 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 ______________ Color of flow _______________________ Results _____________________________________________________Clots? Yes No Color _______________________________________________________Average number of pads you use per day: 1st day ____ 2nd Day ____ 3rd Day ____ 4th day ____ +days _________ First Day of Last Period: ____________Have you been diagnosed with: Fibroids Fibrocystic Breasts Endometriosis Ovarian Cysts PID Other ________________Location of Pain: Lower Abdomen"
(Please indicate before, during or after Menses)
Bearing down sensation ______________________"
________________________________________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
Symptoms related to prostate:Prostate problems
Other __________________________________
__________________________Symptom Survey (for Everyone)________________________________ The following is a list of symptoms that you may or may not ever experience.
Please indicate as follows:
Leave Blank = never experience
check mark()= sometimes plus sign (+) = frequently experience
pain or coldness in the light colored stool
------------------------------- soft brittle nails
feeling the retention of food shortness of breath
tendency to become obsessive decreased sense of smell spasms or twitching of
-------------------------------
insomnia, difficulty sleeping skin problems
feeling of claustrophobiaknee problems
recent use of antibiotics hair loss
Source: http://wellnessconnectionllc.com/downloads/acupuncture_questionnaire.pdf
EXELON CORP. Trailing: RELATIVE NYSE-EXC 44.20 RATIO 12.0 P/E RATIO 0.73 YLD 4.8% LINE Target Price Range TIMELINESS 4 Lowered 2/5/10 2013 2014 2015 1 Raised 6/3/05 BETA .85 (1.00 = Market) 2013-15 PROJECTIONS Ann’l Total Latest recession began 12/07 14% 7% Insider Decisions A M J J A S O N D % TOT. RETURN 1/10 Institutional Decisio
International Journal of Food Microbiology 81 (2002) 1 – 10Identification and antibiotic susceptibility of bacterial isolatesR. Temmermana,*, B. Pot a, G. Huys a, J. Swings a,baLaboratorium voor Microbiologie, Universiteit Gent, K.L. Ledeganckstr. 35, B-9000 Ghent, BelgiumbBCCMTM/LMG Bacteria Collection, K.L. Ledeganckstr. 35, B-9000 Ghent, BelgiumReceived 20 May 2001; received in revis