ACUPUNCTURE FOR YOU

Oriental Diagnosis Form 917-673-2888

This form is evaluated by a Licensed Acupuncturist/herbalist; not a database. The cost is $30 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.

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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 ?
Yes
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 of 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 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 lower back
Sleep - Do you:
Have difficulty going to sleep Awaken during the night Have difficulty returning to sleep Sleep shallowly Have dreams disturb your 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
Are your symptoms and signs: Better with exercise Worse with exercise The same How is your general energy level : Sufficient Too Much Too Little How is your energy level after eating : Same Increased Decreased
Appetite - Do you have :
very poor poor good excessive constant appetite Do you crave this tastes : salty sour bitter sweet spicy Avoid this tastes : salty sour bitter sweet spicy
Digestion - Do you have :
Regular meals Taste your food Have a 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 - 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 your stools Notice a foul or repugnant odor Notice a mucus-like substance in Notice coffee grounds in your stools What color are your stools Number of daily bowel movements
Urine - Do You :
Awaken at night to urinate Have an urgent feeling when you have to urinate Have difficulty starting urination Have an intermittent flow (starting and stopping) Have a weak flow Have pain when you urinate Have pain when you urinate Notice mistiness in your urine Notice cloudiness in your urine Notice a milky quality to 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) Is your liquid intake about equal to your output
Reproduction - Men & Women - Do you :
Have low sexual energy Have excessive sexual energy Have pain during sex Have premature ejaculation Have seminal emission Experience impotence Have itching in/on your genitals Have pain in your genitals Have an odor from your genitals? Have a discharge from your genitals? What color? How often do you engage in sex?
Reproduction - Women
Are you pregnant now or have reason to believe you are cramps during your menstrual flow Are the cramps somewhat painful Are there clots in your menstrual flow How long is your menstrual cycle days Less than 28 days More than 28 days Is it regular: ? Yes No
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 miscarriages?

How many abortions?

Respiration - Do you have:
Shortness of breath Shortness of breath on slight exertion Shortness of breath which is worse when lying down Difficulty inhaling Difficulty exhaling Sneezing Clear phlegm Colored phlegm Small amounts of phlegm large amounts of phlegm Difficulty coughing phlegm up Sinus congestion Sinus infections A cough :? dry wet
Pain - Do you have :
Rapid onset Gradual onset Fixed location pain Shifting location pain Dull pain Sharp pain Burning pain Low back pain Joint pain Pain under the ribs Chest pain Headaches :? Frontal Side Back Behind the eyes
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 Noise in your ears High-pitched Low-pitched Have ear pain Feel pressure in your ears Discharges from your ears
Mouth - Do you have :
Tongue ulcers Bleeding gums Bitter taste in your mouth Other tastes in your mouth
Teeth - What is the condition of teeth ?
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
Emotional/Mental/Thinking - Do you have :
Have poor memory Have mental restlessness Have difficulty concentrating Any stressful experiences Are any of these emotions predominant: ? Fear Anger Joy Shock Worry Sadness
Miscellaneous - 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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