Joseph Bonacci, M.S., L.Ac. Princeton Musculoskeletal Institute

Joseph Bonacci, M.S., L.Ac. Princeton Musculoskeletal Institute

Holistic Vision Acupuncture LLC 3131 Princeton Pike

Tel 609.896.9190 Bldg. 4, Suite 100

Fax 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______

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PRIMARY INSURANCE CO: ______

ADDRESS:______

ID#:______GROUP#:______

NAME OF SUBSCRIBER: ______RELATIONSHIP: ______

SSN OF SUBSCRIBER: ______DOB OF SUBSCRIBER: ______

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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

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 Yes

Hospitalized in the past year? No Yes (please specify why): ______

Had any major surgeries? No Yes (list when and why): ______

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 Spicy

What 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

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 Insomnia

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 Light

Clots: Large Small None

PMS 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 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