form test

Patient Form
Address *
Address
Sex
Marital Status
Have you received Acupuncture before?

Major Complaint(s), in order of significance to you:

Complaint Level
Complaint Level
Complaint Level
Complaint Level

INSTRUCTIONS: Choose a number for the conditions which apply to you.

(1) for MILD symptoms (occurs once or twice a month)

(2) for MODERATE -symptoms (occurs once a week)

(3) for SEVERE symptoms (you are aware of it almost constantly)

IF IT DOES NOT APPLY TO YOU LEAVE IT BLANK

GROUP ONE

Acid foods upset
Gag easily
Appetite reduced
Get chilled, often
Unable to relax; startles easily
Cold sweats often
“Lump” in throat
Extremities cold, clammy
Fever easily raised
Dry mouth-eyes-nose
Strong light irritates
Neuralgia-like pains
Pulse speeds after meal
Urine amount reduced
Staring, blinks little
Keyed up–fail to calm
Heart pounds after retiring
Sour stomach frequent
Cuts heal slowly
“Nervous stomach"
 

GROUP TWO

Joint stiffness after arising
Digestion rapid
“Slow starter”
Muscle-leg-toe cramps at night
Vomiting frequent
Get “chilled” infrequently
“Butterfly” stomach, cramps
Hoarseness frequent
Perspire easily
Eyes or nose watery
Breathing irregular
Circulation poor, sensitive to cold
Eyes blink often
Pulse slow; feels “irregular”
Eyelids swollen,puffy
Gagging reflex slow
Indigestion soon after meals
Difficulty swallowing
Subject to colds, asthma, bronchitis
Always seems hungry; feels “lightheaded” often
Constipation, diarrhea alternating
 

GROUP THREE

Eat when nervous
Heart palpitates if meals missed or delayed
Crave candy or coffee in afternoons
Excessive appetite
Afternoon headaches
Moods of depression –“blues” or melancholy
Hungry between meals
Overeating sweets upsets
Abnormal craving for sweets or snacks
Irritable before meals
Awaken after few hours sleep –hard to get back to sleep
Get “shaky” if hungry
Fatigue, eating relieves
“Lightheaded” if meals delayed
 

GROUP FOUR

Hands and feet go to sleep easily, numbness
Get “drowsy” often
Bruise easily, “black and blue” spots
Sigh frequently, “air hunger”
Swollen ankles worse at night
Tendency to anemia
Aware of “breathing heavily”
Muscle cramps, worse during exercise; get “charley horses”
“Nose bleeds” frequent
High altitude discomfort
Shortness of breath on exertion
Noises in head, or “ringing in ears”
Susceptible to colds and fevers
Dull pain in chest or radiating into left arm, worse on exertion.
Tension under the breast-bone, or feeling of tightness"” worse on exert
Hands and feet go to sleep easily, numbness
Afternoon “yawner”
 

GROUP FIVE

Dizziness
Dry Skin
Burning feet
Blurred vision
Feeling queasy; headache over eyes
Sneezing attacks
Itching skin and feet
Greasy foods upset
Crave sweets
Excessive hair loss
Stools light-colored
Bad breath (halitosis)
Frequent skin rashes
Skin peels on foot soles
Milk products cause distress
Bitter, metallic taste in mouth in mornings
Pain between shoulder blades
Sensitive to hot weather
Bowel movements painful or difficult
Use laxatives
Burning or itching anus
Worrier, feels insecure
Stools alternate from soft to watery
History of gallbladder attacks or gallstones
 

GROUP SIX

Loss of taste for meat
Coated tongue
Indigestion ½ -1 hour after eating; may be up to 3 –4 hrs.
Lower bowel gas several hours after eating
Pass large amounts of foul-smelling gas
Mucous colitis or “irritable bowel”
Burning stomach sensations, eating relieves
Gas shortly after eating
Stomach “bloating” after eating
 

GROUP SEVEN

Insomnia
Failing memory
Dizziness
Nervousness
Low blood pressure
Headaches
Can’t gain weight
Increased sex drive
Hot flashes
Highly emotional
Decreased sugar tolerance
Hair growth on face or body (female)
Flush easily
Abnormal thirst
Sugar in urine (not diabetes)
Night sweats
Bloating of abdomen
Masculine tendencies (female)
Thin, moist skin
Bloating of abdomen
Weakness, dizziness
Inward trembling
Weight gain around hips or waist
Chronic fatigue
Heart palpitates
Sex drive reduced or lacking
Low blood pressure
Increased appetite without weight gain
Tendency to ulcers, colitis
Nails weak, ridged
Pulsefast at rest
Increased sugar tolerance
Tendency to hives
Eyelids and face twitch
Women: menstrual disorders
Arthritic tendencies
Irritable and restless
Young girls: lack of menstrual function
Perspiration increase
Can’t work under pressure
Increase in weight
Bowel disorders
Decrease in appetite
Fatigue easily
Poor circulation
Ringing in ears
Sleepy during day
Swollen ankles
Sensitive to cold
Dry or scaly skin
Crave salt
Constipation
Mental sluggishness
Brown spots or bronzing of skin
Hair coarse, falls out
Headaches upon arising wear off during day
Allergies – tendency to asthma
Slow pulse, below 65
Frequency of urination
Weakness after colds, influenza
Impaired hearing
Reduced initiative
Exhaustion – muscular and nervous
Respiratory disorders
Headaches, “splitting or rending” type
 

GROUP EIGHT

Apprehension
Hair is Coarse and/or thinning
Irritability
Weakness
Morbid fears
Fatigue
Never seems to get well
Skin sensitive to touch
Forgetfulness
Tendency towards hives
Indigestion
Nervousness
Poor appetite
Headache
Craving for sweets
Insomnia
Muscular soreness
Anxiety
Depression/Feeling something dreadful
Anorexia
Noise sensitivity
Inability to concentrate or Confusion
Acoustic hallucinations
Frequent stuffy nose / sinus infection
Tendency to cry without reason
Allergy to some foods
Loose Joints

FEMALE ONLY Section

Very easily fatigued
Hysterectomy/ ovaries removed
Premenstrual tension
Menopausal hot flashes
Painful menses
Menses scanty or missed
Depressed feelings before menstruation
Acne, worse at menses
Menstruation excessive
Depression of long standing
Painful breasts
Menstruate too frequently
Vaginal discharge
Regular menstrual cycle?
Pregnant?
Vaginal Discharge
Bleeding Between periods
Do you experience any of the following?
 
Please fill in the following menstrual chart: If you do not have a cycle please write N/A on the chart below.
 

Color:
 

Amount of flow
 

Pain/Cramps
 

Clots
 

Nausea
 

Vomitting
 

Other Symptons?

MALE ONLY Section

Prostate trouble
Urination difficulty or dribbling
Night urination frequent
Depression
Pain on inside of legs or heels
Feeling of incomplete bowel evacuation
Lack of energy
Migrating aches and pains
Tire too easily
Avoids activity
Leg nervousness at night
Diminished sex drive
Swollen Testes
Testicular Pain
Impotence
Premature ejaculation
Feeling of coldness or numbness in external genitalia