Oriental Diagnosis Form                                                                                              917-673-2888

This form is evaluated by a Licensed Acupuncturist/herbalist; not a database. The cost is $60  and submission of this questionaire through eMail and subsequent telephone follow-up.

The Online Oriental Diagnosis service is  intended only to provide an in-depth acquaintance with Traditional Chinese Medicine which will aid you in deciding whether or not to seek TCM treatment.  It is not intended to be used for self-prescription of Traditional Chinese Medicine treatment.

Type your answers to the questions in the form boxes below and check the box next to the items which apply to you. We make every effort to return your evaluated questionnaire within 48 hours. All Information given on this form is confidential. It is used only for purposes of diagnosis and payment.

E-mail Address: *
Name : *
Address : *
City : *
Zip Code : *
Telephone : *
Date of Birth / Age : *
Describe in your own words main thing you would like help with.
If you have been given a Western Medicine diagnosis what is it?
When did the condition begin?
What were the related circumstances?
To what extent does this condition interfere with your daily activities.
Please list any chronic illnesses or conditions you have had or have now.
Please list any surgeries you have had.
Please list any significant trauma you have had.
Please list all drugs and herbs that you take.
Do you have or have you had any of the conditions listed below ?
Perspiration - Do you:
Perspire on slight exertion,
Perspire for no apparent reason,
Perspire profusely,
Have night sweats,
Have cold sweats,
Have very foul perspiration odor,
Not perspire,
Temperature - Do you:
Tend to feel hot/warm,
Tend to feel cold/cool,
Have a low grade fever all the time,
Have a low grade fever in the afternoon or evening,
Feel warmer in the afternoon or evening,
Have heat or warmth in your palm,
Have heat or warmth in your soles,
Have heat or warmth in your body,
Have deep heat in your body,
Have recurrent fevers,
Have recurrent chills,
Have cold hands,
Have cold feet,
Have chilly arms,
Have chilly legs,
Have cold in your back,
Sleep - Do you:
Have difficulty going to sleep,
Awaken during the night,
Have difficulty returning to sleep,
Sleep shallowly,
Have dreams disturbed sleep,
Have difficulty awakening in the AM,
Feel tired or sleepy during the day,
Need to take naps,
Feel wired and tired,
Get a second wind at night,
Exercise & Energy
How are your symptoms and signs?
Symptoms better with exercise,
Symptoms worse with exercise,
Symptoms remains the same with exercise,
How is your general energy level?
Energy level sufficient,
Energy level too much,
Energy level too little,
How is your energy level after eating?
Energy after eating - same,
Energy after eating - increased,
Energy after eating - decreased,
Appetite - Do you:
Do You:
Have poor appetite,
Have good appetite,
Have excessive appetite,
Have constant appetite,
Do You:
Crave salty taste,
Crave sour taste,
Crave bitter taste,
Crave sweet taste,
Crave spicy taste,
Do you:
Avoid salty taste,
Avoid sour taste,
Avoid bitter taste,
Avoid sweet taste,
Avoid spicy taste,
Digestion - Do you:
Have regular meals,
Taste your food,
Have noisy stomach,
Have indigestion,
Feel like your abdomen is bloated,
Have sour regurgitation or belching,
Have stomach pain or cramping,
Have abdominal pain or cramping,
Have problematic bad breath,
Have flatulence,
Have belching,
Have nausea,
Have vomiting,
Stools / Color / Bowel - Do You:
Tend toward constipation,
Tend toward loose stools,
Have hard stools,
Have soft stools,
Have diarrhea often,
Notice undigested food in your stools
Notice blood in stools,
Notice a foul or repugnant odor,
Notice a mucus-like substance in stools,
Notice coffee grounds in your stools,
What is the color of your stools?
Dark color(stools),
Light color(stools),
Number of daily bowel movements?
1 or 2
More than 2
Urine - Do You:
Awaken at night to urinate,
Have an urgent feeling when you have to urinate,
Have difficulty starting urination,
Have intermitent flow (start & stop),
Have a weak flow,
Have pain when urinate,
Notice mistiness in your urine,
Notice cloudiness in your urine,
Notice milky quality in your urine,
Notice sand or grit in your urine,
Notice blood in your urine,
Have strong smelling urine,
Have urinary tract infections,
What color is your urine (w/o vitamins),
Clear(urine),
Dark(urine),
Your liquid intake about equal to your output?
Yes(intake/output-equal),
No(intake/output-not equal),
No(intake/output-not equal),
Reproduction - Men & Women - Do you:
Have low sexual energy,
Have excessive sexual energy,
Have pain during sex,
Have premature ejaculation,
Have seminal emmision,
Experience impotence,
Have itching in/on genitals,
Have pain in your genitals,
Have an odor from your genitals,
Have a discharge from your genitals? What color?
White(discharge),
Yellow/others(discharge),
How often do you engage in sex?
Often(sex),
Seldom(sex),
Abstinence(sex),
Reproduction - Women
I am pregnant,
I have cramps during my menstrual flow,
The cramps somewhat painful,
There are clots in menstrual flow,
How long is your menstrual cycle(days)?
Cycle less than 28 days,
Cycle more than 28 days,
Is it regular?
Yes(cycle regular),
No(cycle not regular)
How long is your menstrual flow?
What color is your menstrual flow?
Do you use birth control pills? How long?
How many pregnancies have you had?
How many children have you borne?
How many miscariages?
How many abortions?
Respiration - Do you have:
Have shortness of breath,
Have shortness of breath on slight exertion,
Shortness of breath which is worse then lying down,
Difficulty inhaling,
Difficulty exhaling,
Sneezing,
Clear phlegm,
Colored phlegm,
Small amounts of phlegm,
Large amounts of phlegm,
Difficulty coughing phlegm out,
Sinus congestion,
Sinus infections,
A cough?
Dry(cough)
Wet(cough)
Pain - Do you have:
Rapid onset,
Gradual onset,
Fixed location pain,
Shifting location pain,
Dull pain,
Sharp pain,
Burning pain,
Lower back pain,
Joint pain,
Pain under the ribs,
Chest pain,
Headaches?
Frontal(headaches),
Side(headaches),
Back(headaches),
Behind the eyes(headaches),
HEAD TO TOES
Eyes - Do you have:
Change in vision,
Blurry vision,
Red eyes,
Dry eyes,
Gritty eyes,
Poor night vision,
See floaters,
Ears - Do you:
Have difficulty hearing,
Have noise in your ears?
High-pitched(noise),
Low-pitched(noise),
Have ear pain,
Feel pressure in your ears,
Have discharges from ears,
Mouth - Do you have:
Tongue ulcers,
Bleeding gums,
Bitter taste in your mouth,
Other tastes in your mouth,
Teeth - What is the condition?
Excellent
No fillings or crowns
Few fillings or crowns
Many fillings or crowns
Throat - Do you have:
Mild sore throats often,
Difficulty swallowing,
Sensation of something in your throat,
Phlegm in your throat,
Nose - Do you have:
Obstructed nose,
Nosebleeds,
Dry nose,
Where do you have muscle weakness?
Where do you have muscle tension?
Do you have :
Muscle aches,
Muscle cramps,
Muscle tics,
Muscle spasm,
Mental/Thinking/Emotions - Do you have:
Have poor memory,
Have mental restlessness,
Have difficulty concentrating,
Have stressful experience,
Fear,
Anger,
Joy,
Shock,
Worry,
Sadness,
Miscellaneous/Heaviness - Do you:
Feel your heart beat,
Have dizziness,
Have brittle nails,
Have thirst without a desire to drink,
Have rashes,
Have itching,
Have a feeling of heaviness: ?
Body,
Head,
Arms or legs,

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