Traditional Chinese Medicine Diagnostic 10 Questions Please answer each question.

Size: px
Start display at page:

Download "Traditional Chinese Medicine Diagnostic 10 Questions Please answer each question."

Transcription

1 1 Traditional Chinese Medicine Diagnostic 10 Questions Please answer each question. 1. Thinking about your internal thermostat and where you feel your body temperature is most of the day, do you think that you are usually (Circle One) a. Hotter than those around you b. Colder than those around you c. Same as those around you. 1a. Do you have hot flashes? Y N 1b. Do you have cold hands and feet? Y N How thirsty you usually feel? (Circle one) 1c. Not Thirsty at all 1d. Normal thirst for environmental conditions 1e. Very Thirsty 2. Do you sweat when you exercise? Y N 2a. Do you sweat when sitting quietly? Y N 2b. Do you have night sweats? Y N 2c. Do you think that you sweat excessively? Y N 3. Do you wake feeling rested? Y N 3a. Do you have trouble falling asleep? Y N 3b. Do you have trouble staying asleep? Y N 3c. How many times do you wake at night? 3d. What time of night do you typically awaken? 4. Do you get hungry? When you eat, do you get full? Y N 4a. Do you crave sugar? Y N 4b. Do you crave salt? Y N 4c. Do you have any other flavor cravings? 5. Do you consider your digestion normal? Y N 5a. Do you tend to have gas? Y N 5b. Do you tend to have bloating? Y N 5c. Do you tend to be constipated? Y N 5d. Do you tend to have diarrhea? Y N 5e. Do you tend to have bowel pain? Y N 5f. Do you tend to have frequent burping? Y N 5g. Do you tend to have frequent nausea? Y N

2 2 6. Do you wake up at night to urinate? Y N 6a. If you do, about how many times per night? 6b. Is your urine typically pale and clear? Y N 6c. Is your urine typically dark or concentrated? Y N 6d. Do you lose your urine when you cough, sneeze or have a full bladder? Y N 7. Are you still having a menstrual period? Y N If you are not still having a menstrual period, please answer the following based on your most typical menstrual period in the past. 7a. Were or are your periods regular? Y N 7b. Did you or do you have blood clots larger than a nickel? Y N 7c. On the line below, mark the color of your menstrual blood from brighter red (R) to darker maroon (M)? R M 7d. Did or do you have severe pain with your periods? Y N 7e. Did or do you tend to have mood changes before your periods? Y N 7f. How many days did or do your period last? 7g. How many days were or are your cycles? 8. Do you typically have an energy drop at a certain time of day? Y N 8a. If you do have an energy drop, usually at what time of day? 8b. Mark on the line where your energy is right now using the scale: 0 (no energy) to 10 (excessive energy) Place a mark on the line to indicate on a scale of 0 (none) to 10 (worst imaginable), to show how much pain are you having right now. 0 10

3 3 9a. Please tell us about your pain. Circle as many as apply: -Burning- -Dull- -Achy- -Sharp- -Stabbing- Better with: Pressure Warmth Cold Worse with: Pressure Warmth Cold 10. Place a mark on the line where you would characterize your predominant mood? Happy Sad Content Angry Carefree Worried Practitioner s Exam and Diagnostic Work Sheet Tongue Diagnosis Circle choices provided or write in other findings Body color: red pink pale Body quality: puffy significantly swollen thin fat other shape Body moisture: moist wet dry Coat color: White yellow gray black none other Coat thickness: thick thin Coat moisture: moist dry greasy Sublingual veins: flat distended engorged other Other significant tongue features: teeth indentations macules other

4 4 Pulses Right cun chi guan Left cun chi guan Quality of pulse: Choices: floating, flooding, empty, scattered, hollow, leather, soft, minute; sinking, hidden, firm, full, weak, thin, slow, leisurely, choppy, knotted, intermittent, rapid, slippery, tight, hasty, moving, long, wiry, short (Huynh & Seifert, 1981) Right Cun Guan Chi Left Cun Guan Chi Diagnosis Organs Involved: Rank Liver Kidney Spleen Heart Lungs Pericardium Gall Bladder Bladder Stomach Small Intestine Large Intestine Triple Burner

5 5 Diagnosis, Appearance and Other information: 52 Diagnosis: 1. Liver Qi Constraint: Liver Blood Xu: Liver Yin Xu: Liver Wind: Liver Yang Rising: Liver Heat: Liver Fire Blazing: Qi and Blood Stagnation: Heart Xu: Yin / Blood / Qi / Yang (Circle one. If more than one enter in Other): Spleen Qi Xu: Spleen Damp: Kidney Yang Xu: Kidney Qi Xu: Kidney Yin Xu: Kidney Jing Xu: Damp Heat Retention: Wind-cold invasion: Other: Other:

Tongue Evaluation. Body Color. Including colors at different locations. Indications. Body temperature regulation.

Tongue Evaluation. Body Color. Including colors at different locations. Indications. Body temperature regulation. Tongue Evaluation Christopher Rodgers, Student Body. Refers to the overall appearance including muscles, arteries, and veins. Associations. Conditions of the cardiovascular, nervous, reproductive, urinary

More information

CMCS121. Session 4. Interview Workshop/ Abdominal Pain. Chinese Medicine Department.

CMCS121. Session 4. Interview Workshop/ Abdominal Pain. Chinese Medicine Department. CMCS121 Session 4 Interview Workshop/ Abdominal Pain Chinese Medicine Department www.endeavour.edu.au Abdominal Pain o Maciocia, p 145-147, o Pain, p 255-259, 735-745 o Digestive symptoms p 262, o Asking

More information

Course: Diagnostics II Date: Class #: 2

Course: Diagnostics II Date: Class #: 2 Course: Diagnostics II Date: 10-03-07 Class #: 2 Eight principles cont d Know: what is true/what is false (true cold/false heat for example) Know yin deficiency symptoms Know exterior/interior dx. Note:

More information

Upper Jiao problem Pallor of face Qi/Yang/Blood Xu or Cold Can be excess, or Blood Deficiency

Upper Jiao problem Pallor of face Qi/Yang/Blood Xu or Cold Can be excess, or Blood Deficiency Course: Diagnostics II Date: Dec 8, 2007 Combination Symptoms Combination Syndrome Symptom Caused by Qi Deficiency of Heart and Lung Palpitation Indicative of heart problem Cough with difficult inhalation,

More information

CONSULTATION & CONSENT FORMS p. 1 of 5

CONSULTATION & CONSENT FORMS p. 1 of 5 CONSULTATION & CONSENT FORMS p. 1 of 5 ******************************************************************************** List your full name, age, sex, and today's date List your complete address List your

More information

Emotional Relationships Social Life Sexually Recreation

Emotional Relationships Social Life Sexually Recreation Name Date Address City State Zip Married Single Partner Divorced Widowed Date of Birth SS# Email Work Phone Home Phone Cell Phone Occupation Referred by Emergency Contact Family Physician Contact May we

More information

DIAGNOSIS YES NO. KIDNEY YIN DEFICIENTY (Ki Yi- -) Do you have lower back weakness, soreness, or pain, or knee problems?

DIAGNOSIS YES NO. KIDNEY YIN DEFICIENTY (Ki Yi- -) Do you have lower back weakness, soreness, or pain, or knee problems? Answer yes or no to each of the following questions. Don t worry about what the symptoms mean; just note whether you experience them. If you have more than one--fourth to one--third yes re- sponses in

More information

Course: Diagnostics I Date: August 14, 2007 Class #: 7. Drinking (pt of Q5)

Course: Diagnostics I Date: August 14, 2007 Class #: 7. Drinking (pt of Q5) Course: Diagnostics I Date: August 14, 2007 Class #: 7 For quiz review the 10 trad questions, 16 questions. And more. 10 Traditional q s (cont d) Thirsty? Ask this first. Most important question. Drinking

More information

四 Differentiation on Liver and G.B.

四 Differentiation on Liver and G.B. 四 Differentiation on Liver and G.B. The main physiological function of the liver is in charge of promotion of free flow of whole body s Qi and storing the blood. The common pathogenic changes of liver

More information

Table 1. Traditional Chinese Medicine Syndrome Differentiation Diagnostic Criteria for Apoplexy Scale

Table 1. Traditional Chinese Medicine Syndrome Differentiation Diagnostic Criteria for Apoplexy Scale Table. Traditional Chinese Medicine Syndrome Differentiation Diagnostic Criteria for Apoplexy Scale TCM Item Acute ischemic stroke related symptoms and signs Score Wind Onset Peaked 8 hours Peaked hours

More information

Associations of Yin & Yang Yin Disorders

Associations of Yin & Yang Yin Disorders Review ChiroCredit.com Presents: AcuPractice 202 Yin & Yang II, The 8 Principles Yin vs. Yang Substance vs. Function Cooling vs. Warming Activity vs. Rest Protection vs. Recovery Transformation vs. Maintenance

More information

Class 1 - Point Indication. Review of TCM theory. Yin / Yang ( / Yin and Yang are:

Class 1 - Point Indication. Review of TCM theory. Yin / Yang ( / Yin and Yang are: Class 1 - Point Indication Review of TCM theory Yin / Yang ( / Yin and Yang are: 1. Counterbalanced They are the generalization of the relative opposite principles observed throughout all things 2. Inter-transforming

More information

Patient Information. Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland

Patient Information. Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland Patient Information Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland 21014 410-913-8322 Patient Name: Date of Birth: Age: Male: Female: Single: Married: Separated:

More information

METABOLIC ASSESSMENT FORM

METABOLIC ASSESSMENT FORM METABOLIC ASSESSMENT FORM Name: Age: Sex: Date: PART 1 Please list the 5 major health concerns in your order of importance: 1. 2. 3. 4. 5. PART 2 Please circle the appropriate number 0-3 on all questions

More information

Traditional Chinese Medicine (TCM) Assessment Instructions

Traditional Chinese Medicine (TCM) Assessment Instructions Traditional Chinese Medicine (TCM) Assessment Instructions This assessment form is designed to determine your current health condition according to Traditional Chinese Medicine (TCM). Each patient must

More information

New Patient Medical History Intake Form

New Patient Medical History Intake Form New Patient Medical History Intake Form Name: Todays Date: / / Date of Birth: / / Age: Gender: M / F Marital Status: S M D W Address: City: State: Zip Code Primary Ph.# (cell, hm, wk) Email Address 2nd

More information

WOMEN S FITNESS TIPS HEALTH ASSESSMENT QUESTIONNAIRE

WOMEN S FITNESS TIPS HEALTH ASSESSMENT QUESTIONNAIRE WOMEN S FITNESS TIPS HEALTH ASSESSMENT QUESTIONNAIRE Name: Date: This is not a test, or a quiz, and there are NO right or wrong answers here. This health assessment questionnaire is about YOU, and will

More information

ACUPUNCTURE FOR HEALTH WENDY STALKER R.Ac. Dip.Ac. B.Sc. Name: Date of Birth: Date:

ACUPUNCTURE FOR HEALTH WENDY STALKER R.Ac. Dip.Ac. B.Sc. Name: Date of Birth: Date: Name: Date of Birth: Date: Address: Postal Code: Occupation: Telephone: Day: Cell Phone: E-mail address: Emergency Contact: Evening: Telephone: Male Female Where did you hear about Acupuncture for Health?

More information

PHLEGM. Signs of Phlegm The essential signs of Phlegm are a Swollen tongue body with a sticky tongue coating and a Slippery or Wiry pulse.

PHLEGM. Signs of Phlegm The essential signs of Phlegm are a Swollen tongue body with a sticky tongue coating and a Slippery or Wiry pulse. PHLEGM The concept of Phlegm is very wide-ranging and important in Chinese Medicine. Phlegm is extremely frequent in clinical practice and is at the same time a pathological condition and an aetiological

More information

Lung and Large Intestine

Lung and Large Intestine Course: Diagnostics II Date: October 17, 2007 Class #: 4 Homework For each zang or fu: make a small chart for each for symptoms. Do a chart per organ, later do a chart with combinations. See slide 9 from

More information

Have you had all childhood diseases i.e.? chickenpox. Y N. Have you ever suffered from an infectious illness? i.e. glandular fever.

Have you had all childhood diseases i.e.? chickenpox. Y N. Have you ever suffered from an infectious illness? i.e. glandular fever. Acupuncture case history card Name: Date: Address: Ph No: (H) (W) (M) E-mail: Fax: D.O.B Sex: M F Marital Status: Occupation: Dr: Suburb: Referred by: Health fund Medical history For the following questions,

More information

Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist

Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist *All information is important to your intake and valuable to your personal treatment plan. Please answer as thorough as possible. Patient Information: Name: Date: / / (First Middle Last) Address: City:

More information

Symptom Questionnaire

Symptom Questionnaire Symptom Questionnaire The following questionnaire is a general assessment of your health developed by Dr Royal Lee D.D.S. Each grouping represents a particular area of your body that may be causing you

More information

ALIGN ACUPUNCTURE AND HERBS LLC Rebekah V. Michaels MAOM, Diplomate OM, Lic Ac

ALIGN ACUPUNCTURE AND HERBS LLC Rebekah V. Michaels MAOM, Diplomate OM, Lic Ac ALIGN ACUPUNCTURE AND HERBS LLC Rebekah V. Michaels MAOM, Diplomate OM, Lic Ac. 617-835-2512 Patient Information and Health History Date: Name: Date of Birth: Street: City: State: Zip: Phone: (H) (W) )

More information

Symptom Review (page 1) Name Date

Symptom Review (page 1) Name Date v2.4, 2/13 JonathanTreasure.com Botanical Medicine & Cancer Herb Drug Interactions Herbalism 3.0 Symptom Review (page 1) Name Date INSTRUCTIONS Please read each section below carefully and, after each

More information

TONICS TO TONIFY OR TO EXPEL: THAT IS THE QUESTION

TONICS TO TONIFY OR TO EXPEL: THAT IS THE QUESTION TONICS "The three months of Autumn are the time of harvest. The energy of Heaven begins to blow swiftly and the energy of Earth begins to change colour. One should go to bed early and rise early: maintain

More information

Patient Information & Health History

Patient Information & Health History Patient Information & Health History Name Date Date of Birth (mm/dd/yy) Age Male Female Address City Postal Code Occupation Phone (H) E-mail Phone (C) Married Single Divorced Widowed Phone (W) Spouse s

More information

Treatment Principle Basics

Treatment Principle Basics Treatment Principle Basics Blood : Main TX: Nourish Blood + Tonify the Organ so: : Heart Blood Nourish Blood, tonify HT Calm Mind Pericardium Blood Nourish Blood, strengthen Heart and Pericardium Move

More information

FAMILIES OF REMEDIES

FAMILIES OF REMEDIES FAMILIES OF REMEDIES This newsletter will present the main "families" of remedies grouped according to condition treated in a tabular form for quick reference. The "families" of remedies considered will

More information

POST GRADUATE DIPLOMA IN ACUPUNCTURE (PGDACP) Term-End Examination December, 2010 PGDACP-01 : BASIC THEORIES OF ACUPUNCTURE/TCM DIAGNOSIS

POST GRADUATE DIPLOMA IN ACUPUNCTURE (PGDACP) Term-End Examination December, 2010 PGDACP-01 : BASIC THEORIES OF ACUPUNCTURE/TCM DIAGNOSIS No. of Printed Pages : 11 PGDACP - 01 l POST GRADUATE DIPLOMA IN ACUPUNCTURE (PGDACP) 00061 Term-End Examination December, 2010 PGDACP-01 : BASIC THEORIES OF ACUPUNCTURE/TCM DIAGNOSIS Time : 2 Hours Maximum

More information

HOW DID YOU HEAR ABOUT US?

HOW DID YOU HEAR ABOUT US? 427 Bloomfield Ave. Ste. 306 Montclair, NJ 07042 Phone: 973-746- 2848 Fax: 973-746- 2088 HOW DID YOU HEAR ABOUT US? Eastern School of Acupuncture and Traditional Medicine Student Clinic Intake Form Intake

More information

INTERNAL CANON OF THE YELLOW EMPEROR TCM DIAGNOSIS METHODS. Stanley Liang Ph.D., R.TCMP, R.Ac

INTERNAL CANON OF THE YELLOW EMPEROR TCM DIAGNOSIS METHODS. Stanley Liang Ph.D., R.TCMP, R.Ac INTERNAL CANON OF THE YELLOW EMPEROR TCM DIAGNOSIS METHODS Stanley Liang Ph.D., R.TCMP, R.Ac Text reading S17 Discussion on the Essentials of Pulse S18 Discussion on the Pulse Conditions of Healthy People

More information

The Theory of Chinese Medicine

The Theory of Chinese Medicine 1 The Theory of Chinese Medicine The Linking Thread The five therapies of Chinese medicine are acupuncture, herbs, tui na massage, diet and Qigong. Each therapy is practised in its own special way. Acupuncturists

More information

Chinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone: Emergency contact name & phone number: Relationship Status:

Chinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone:   Emergency contact name & phone number: Relationship Status: Chinese Medicine Adult Intake Form Name (Last, First): Date of Birth: Occupation: Hours per week: Home address: Phone: Email: Preferred contact method (circle one): Phone / Email Emergency contact name

More information

4-1 Dyspnea (Chuan, 喘 )

4-1 Dyspnea (Chuan, 喘 ) 4-1 Dyspnea (Chuan, 喘 ) Concept Breathing with difficulty (open wide mouth, raise shoulders) Etiology and pathogenesis Climatic factors Phlegm fluid Emotion Chronic diseases Exertion Over sex Diagnosis

More information

Heavenly Qi Podcast 5 Element Blocks to Treatment

Heavenly Qi Podcast 5 Element Blocks to Treatment F I V E E E M E N T A C U P U N C T U E S E M I N A S G Y E B E N N E T T S I C. A C. ( U. K. ) M. B. A C. C. A. T. M. S. E G I S T E E D A C U P U N C T U I S T Heavenly Qi Podcast 5 Element Blocks to

More information

Qi & Blood Deficiency Signs. Qi & Blood Deficiency Signs. Weak voice and lack of desire to speak. Chinese Pathology of 10

Qi & Blood Deficiency Signs. Qi & Blood Deficiency Signs. Weak voice and lack of desire to speak. Chinese Pathology of 10 Qi & Blood Deficiency Signs Qi Deficiency Blood Deficiency Qi & Blood Deficiency Signs Qi Deficiency Pale bright complexion Shortness of breath Weakness/Exhaustion (Lassitude of spirit) Weak voice and

More information

Women s Fertility Symptom Survey

Women s Fertility Symptom Survey 535 Encinitas Blvd., Suite 115 Encinitas, CA 92024 (760) 575-4227 www.capwellnesscenter.com Women s Fertility Symptom Survey Please answer the following questions even if you have encountered the same

More information

HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM

HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM 1 UT Health Austin Comprehensive Pain Management New Patient Questionnaire Thank you for scheduling a visit with the Comprehensive Pain Management Care Team. The responses you provide to these questions

More information

HORMONAL LEVELS SELF TEST. Date Full Name No.

HORMONAL LEVELS SELF TEST. Date Full Name No. HORMONAL LEVELS SELF TEST Date Full Name No. This self-test to help your doctor if your levels of hormones are below normal. Circle the score for each line then total the score at the bottom of each hormone.

More information

DIFFERENTIAL QUESTIONS

DIFFERENTIAL QUESTIONS 4 IMBALANCES AND 5 ORGANS A New System for Diagnosis and Treatment DIFFERENTIAL QUESTIONS Jeremy Ross www.jeremyross.com DIFFERENTIAL QUESTIONS A New System for Diagnosis 90 Organ syndromes In Chinese

More information

Differentiation in lung and L.I.

Differentiation in lung and L.I. Differentiation in lung and L.I. The main physiological function of the lung is in charge of breathing, supplements heart for blood circulation, and regulates the water metabolism. It s common manifestation

More information

Metabolic Assessment Form

Metabolic Assessment Form Metabolic Assessment Form Approach Wellness and Aesthetics 200 Forsythe Street Fayetteville, NC 28303 Office: (910) 322-7368 Fax: (910) 483-5796 www.tawellness.net Name: Age: Sex: Date: Part 1: Please

More information

Sixfu organs: small intestine, gall bladder, stomach, Large intestine, urinary bladder

Sixfu organs: small intestine, gall bladder, stomach, Large intestine, urinary bladder Sixzang organs: heart, liver, spleen, lung, kidney, pericardium To manufacture and store essential substances including vital essence, qi (vital energy), blood, andbodyfluid Sixfu organs : small intestine,

More information

PHYSIOTHERAPIST. Date of last visit MASSAGE THERAPIST. Date of last visit SPECIALISTS. Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS?

PHYSIOTHERAPIST. Date of last visit MASSAGE THERAPIST. Date of last visit SPECIALISTS. Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS? 2 PHYSIOTHERAPIST Date of last visit MASSAGE THERAPIST Date of last visit SPECIALISTS Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS? WHAT IS THE PRIMARY REASON YOU ARE SEEKING CONSULTATION/TREATMENT?

More information

CHEMOTHERAPY. What should I expect?

CHEMOTHERAPY. What should I expect? CHEMOTHERAPY What should I expect? WHAT IS CHEMOTHERAPY? Chemotherapy is treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy

More information

IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE CARRIER TO MAKE SURE YOUR VISIT WILL BE COVERED

IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE CARRIER TO MAKE SURE YOUR VISIT WILL BE COVERED Appointment Date: Appointment Time: Patient: Welcome to The Pain Management Center with services provided by American Health Network. Please keep this information and let it serve as a reminder for your

More information

URINARY DISORDERS: Lin Syndromes. Linda Boggie Eric Hartmann

URINARY DISORDERS: Lin Syndromes. Linda Boggie Eric Hartmann URINARY DISORDERS: Lin Syndromes Linda Boggie Eric Hartmann Lin Syndromes Painful Urination Syndromes Painful Frequent Short Urgent Dribbling A disruption in urine flow Often associated with or are an

More information

CMPR121. Session 13. Small Intestine

CMPR121. Session 13. Small Intestine CMPR121 Session 13 Small Intestine Chinese Medicine Department www.endeavour.edu.au Small Intestine o Separates the pure from the impure o Receives & transports food o Separates fluids o Is responsible

More information

Metabolic Assessment Form Please list your five major health concerns in your order of importance.

Metabolic Assessment Form Please list your five major health concerns in your order of importance. Metabolic Assessment Form Please list your five major health concerns in your order of importance. 1. 2. 3. 4. 5. Please check the appropriate number on all questions below, using zero as least/never to

More information

! 30 E Padonia Rd, #305, Timonium, MD Phone: (410) Fax: (443)

! 30 E Padonia Rd, #305, Timonium, MD Phone: (410) Fax: (443) ! 30 E Padonia Rd, #305, Timonium, MD 21093 Phone: (410) 560-7404 Fax: (443) 705-0228 Email: info@waynebonliemd.com Today s Date: Patient Information Name: DOB: / / Address: City/Town: State: Zip: Home

More information

Term-End Examination December, 2009

Term-End Examination December, 2009 PGDACP - 01 POST GRADUATE DIPLOMA IN ACUPUNCTURE (PGDACP) 00931 Term-End Examination December, 2009 PGDACP-01 : BASIC THEORIES OF ACUPUNCTURE/TCM DIAGNOSIS Time : 2 Hours Maximum Marks : 70 Note : There

More information

Course: Diagnostics II Date: 9/26/07 Class #: 1

Course: Diagnostics II Date: 9/26/07 Class #: 1 Course: Diagnostics II Date: 9/26/07 Class #: 1 Theories of disease and symptom analysis to acquire differentiation. There are several tools and systems you can use to analyze symptoms and get form a differentiation

More information

NEW PATIENT INTAKE FORM

NEW PATIENT INTAKE FORM NEW PATIENT INTAKE FORM Acupuncture * Herbs * Nutrition Located inside of Yoga 360 91 Bankview Drive Frankfort, IL 60423 815-806-0360/www.yoga-360.com lkacupuncture.com lizkelchak@gmail.com How To Prepare

More information

Pain Clinic Packet Neal E. Coleman, MD Andrew Trobridge, MD Angelia Huffmeyer, FNP J. Mark Hannaford, PA Matthew Stinson, PA-C

Pain Clinic Packet Neal E. Coleman, MD Andrew Trobridge, MD Angelia Huffmeyer, FNP J. Mark Hannaford, PA Matthew Stinson, PA-C Appointment Date: Appointment Time: Patient: Welcome to The Pain Management Center with services provided by American Health Network. Please keep this information and let it serve as a reminder for your

More information

ACUPUNCTURE INTAKE FORM

ACUPUNCTURE INTAKE FORM , ND ACUPUNCTURE INTAKE FORM Thank you for taking the time to complete the following new patient forms. Given this form is extensive, it plays an integral role in achieving our mutual goal of your optimal

More information

Metformin and bright yellow diarrhea

Metformin and bright yellow diarrhea Metformin and bright yellow diarrhea This article reveals the shocking truth about liver flush/gallstone cleanse and tells you why you need to avoid this unhealthy practice. 17-2-2018 This is the most

More information

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information Patient General Information Name: (first) (middle) (last) Date of Birth: / / (mo) (day) (year) 中 文名字 : Gender: Occupation: Address: (street, apt) Phone #: (city, state, zip code) Email: Emergency Contact:

More information

DISEASES OF THE RESPIRATORY SYSTEM

DISEASES OF THE RESPIRATORY SYSTEM DISEASES OF THE RESPIRATORY SYSTEM Respiratory diseases are extremely common and often respond very well to treatment with acupuncture and Chinese herbs. Both acute and respiratory diseases can be helped.

More information

New Patient Health History Questionnaire

New Patient Health History Questionnaire Name:. Dear Nov Patient: a) Please read and fill in all of the information that pertains to you. b) On pages 2 through 11, under each category, check all symptoms that you experience either acutely or

More information

Name: Date of Birth: Age: Address: City State Zip

Name: Date of Birth: Age: Address: City State Zip Today s Date: Client History Name: Date of Birth: Age: Address: City State Zip Cell Phone: Home Phone: Work Phone: Email Address: Female Male Emergency Contact: Phone Number: How did you hear about us?

More information

Dang Gui Si Ni Tang Tangkuei Decoction for Frigid Extremities

Dang Gui Si Ni Tang Tangkuei Decoction for Frigid Extremities Dang Gui Si Ni Tang Tangkuei Decoction for Frigid Extremities D F E G ctions: Warms the channels, disperses cold, nourishes the xue, and unblocks the xue vessels. hief Deputy (a) Dang Gui (b) Gui Zhi (c)

More information

Introduction of Korean Acupuncture focusing on Saam Five Element Acupuncture and Facial Acupuncture

Introduction of Korean Acupuncture focusing on Saam Five Element Acupuncture and Facial Acupuncture Introduction of Korean Acupuncture focusing on Saam Five Element Acupuncture and Facial Acupuncture Sanghoon Lee MD(Korean Medicine), MPH, PhD, DiplAc, LAc.(USA) Professor of Acupuncture & Moxibustion

More information

Patient Health History

Patient Health History Patient Health History Name: Date: Address: City, State, Zip code Phones: Home Work: Cell: Email address: Date of Birth: Age: Occupation: Emergency contact: Referred by: Current Medications: Are you/might

More information

QI STAGNATION AETIOLOGY. The aetiological factors of Qi stagnation are essentially only two, i.e. emotional or dietary.

QI STAGNATION AETIOLOGY. The aetiological factors of Qi stagnation are essentially only two, i.e. emotional or dietary. QI STAGNATION This newsletter will discuss the aetiology, pathology, patterns and treatment of Qi stagnation. Qi stagnation is one of the most common pathological situations encountered in practice and

More information

Hormone Deficiency Tests

Hormone Deficiency Tests Hormone Deficiency Tests ESTROGEN SIGNS & SYMPTOMS NEVER SOMETIMES REGULARLY OFTEN CONSTANTLY 1 I am losing hair on top of my head. 2 I'm getting thin, vertical wrinkles above my lips. 3 My breasts are

More information

Five Element Intake Form

Five Element Intake Form Five Element Intake Form (This check list is just a sampling of Five Element criteria that are used in diagnosis. You can use it by simply checking off those items that pertain to your constitution or

More information

ACUPUNCTURE SPECIFIC INTAKE FORM

ACUPUNCTURE SPECIFIC INTAKE FORM ACUPUNCTURE SPECIFIC INTAKE FORM A naturopathic approach to medicine is holistic and seeks to understand all factors that may be affecting your health. Please answer the following questions to the best

More information

Patient Health History for Fertility

Patient Health History for Fertility Patient Health History for Fertility Name: Date: Address: City, State, Zip code Phones: Home Work: Cell: Email address: Date of Birth: Age: Occupation: Emergency contact: Ob/Gyn: Current Medications: What

More information

Patient Intake Form for Acupuncture Treatment at Infinite Healing

Patient Intake Form for Acupuncture Treatment at Infinite Healing Section A: Your Information Patient Intake Form for Acupuncture Treatment at Infinite Healing Last Name: First Name: Middle Initial: Mailing Address: _ City: Postal Code: E-mail: Birth date: M D YR Age:

More information

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome:

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome: MenoChat Patient Health History Questionnaire Patient Name (last, first, MI): How did you hear of MenoChat? Address City State Zip Code Home Phone #: Cell Phone #: Male or Female Marital Status Email Employer

More information

Head To Heal Acupuncture Intake

Head To Heal Acupuncture Intake Form Head To Heal Acupuncture Intake Patient Name: Date of Birth: / / Address: Phone: In case of emergency contact (name & #): Consent to treat with acupuncture (signature): Major Concerns: 1) 3) 2) 4)

More information

Health Fact Sheet Basics of Traditional Chinese Medicine

Health Fact Sheet Basics of Traditional Chinese Medicine Health Fact Sheet Basics of Traditional Chinese Medicine Traditional Chinese Medicine (TCM) is one of the oldest systems of medicine in the world it has developed for 2,500 years from practical experience

More information

Kidney Yang Deficiency

Kidney Yang Deficiency Chinese Pathology 2 6-11-05 Table of Contents Kidney Yang Deficiency...1 Water phlegm goes into the upper jiao... 1 Spleen/kidney yang deficiency... 1 Qi Absorption Failure... 3 Heart-kidney yang debilitation...4

More information

Term-End Examination June, 2010

Term-End Examination June, 2010 00643 No. of Printed Pages : 12 PGDACP - 01 POST GRADUATE DIPLOMA IN ACUPUNCTURE (PGDACP) Term-End Examination June, 2010 PGDACP-01 : BASIC THEORIES OF ACUPUNCTURE/TCM DIAGNOSIS Time : 2 Hours Maximum

More information

Address: Phone: Date of Birth: / / Major Complaints: 1) 3) 2) 4)

Address: Phone:   Date of Birth: / / Major Complaints: 1) 3) 2) 4) Head To Heal Family Wellness Acupuncture Intake Form Patient Name: Address: Phone: email: Date of Birth: / / Major Complaints: 1) 3) 2) 4) Details regarding Major Complaint: Where is the problem located?

More information

(city) (State) (zip)

(city) (State) (zip) ACUPUNCTURE PATIENT INTAKE FORM DATE: / / NAME: DATE OF BIRTH: / / AGE SEX: M F HEIGHT: WEIGHT: ADDRESS: (street) (city) (State) (zip) PHONE: / / (Home) (Work) (Cell) E-MAIL: EMERGENCY CONTACT: Name: Address:

More information

Balanced Healing Acupuncture, LLC

Balanced Healing Acupuncture, LLC Balanced Healing Acupuncture, LLC Intake Form NAME: Last First: GENDER: Date of Birth / / Age Email Address Address City State Zip Code Preferred Phone Number Cell Home Work Preferred Method of Communication:

More information

What do you believe is causing your most important health concern?

What do you believe is causing your most important health concern? Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to

More information

The RBE Toxicity Quiz: How Full Is Your Rain Barrel?

The RBE Toxicity Quiz: How Full Is Your Rain Barrel? The RBE Toxicity Quiz: How Full Is Your Rain Barrel? In industrialized societies cancer is second only to cardiovascular disease as a cause of death. But in ancient times, cancer was extremely rare. There

More information

SYSTEMS SURVEY FORM. Doctor

SYSTEMS SURVEY FORM. Doctor Patient Birth Date / / Approx Weight SYSTEMS SURVEY FORM Doctor INSTRUCTIONS: Fill in only the circles which apply to you. Leave blank if you don't have the problem. Fill in the circle marked 1 for MILD

More information

For the Patient: Ponatinib Other names: ICLUSIG

For the Patient: Ponatinib Other names: ICLUSIG For the Patient: Other names: ICLUSIG (poe na' ti nib) is a drug that is used to treat some types of cancer. It is a tablet that you take by mouth. The tablet contains lactose. Tell your doctor if you

More information

Used for exterior conditions such as common colds, fevers, and flu s. Many of these formulas induce sweating. This category can be subdivided into

Used for exterior conditions such as common colds, fevers, and flu s. Many of these formulas induce sweating. This category can be subdivided into Section 1 Used for exterior conditions such as common colds, fevers, and flu s. Many of these formulas induce sweating. This category can be subdivided into formulas the release cold or heat. Traditionally

More information

Bodily Conditions Rooted in Hormone Imbalance

Bodily Conditions Rooted in Hormone Imbalance Check this list for all conditions that apply to you. The total possible score is 209. Count the number of symptoms you check. The higher your score, the more likely you need to address hormone imbalances.

More information

Health History Questionnaire

Health History Questionnaire CLINICAL ACUPUNCTURE SERVICES Cathy D. Adelman, RN, LAc PO Box 91451 Tucson, AZ 85752-1451 (520) 822-6844 cdarnlac@hughes.net www.clinicalacupunctureservices.com Health History Questionnaire I. GENERAL

More information

!!!! Traditional & Contemporary Acupuncture! 19 Golden Ave, Toronto ON! ! Gregory Cockerill, R.

!!!! Traditional & Contemporary Acupuncture! 19 Golden Ave, Toronto ON! ! Gregory Cockerill, R. Traditional & Contemporary Acupuncture 19 Golden Ave, Toronto ON info@livehandacupuncture.com 416-899-3364 Gregory Cockerill, R.Ac First Name: Last Name: Birthdate: Gender: Female Male Address: Email:

More information

Contents. Basic Theory of Acupuncture. (Page 1) Acupuncture Points. (Page 31) Side Effects of Acupuncture. (Page 51)

Contents. Basic Theory of Acupuncture. (Page 1) Acupuncture Points. (Page 31) Side Effects of Acupuncture. (Page 51) VII Contents Basic Theory of Acupuncture (Page 1) Scientific Aspects of Acupuncture..................... 2 Indication and Direction of Action of Acupuncture.................................... 12 Relative

More information

SYSTEMS SURVEY FORM GROUP 1

SYSTEMS SURVEY FORM GROUP 1 SYSTEMS SURVEY FORM Patient Doctor Date Birth Date / / Approx Weight Vegetarian Gluten-free INSTRUCTIONS: Number only the boxes which apply to you. Leave blank if you don't have the problem. * Write 1

More information

55 S. Main Street, Driggs, ID (208)

55 S. Main Street, Driggs, ID (208) Elements of Health 55 S. Main Street, Driggs, ID 83422 (208) 920-0312 Name: (first) (middle) (last) Date: / / Address: Phone: / street address city zipcode home / cell Date of Birth: / / Age: Gender: M/F

More information

Syndrome Differentiation. REVIEW Dr Igor Mićunović Ph.D

Syndrome Differentiation. REVIEW Dr Igor Mićunović Ph.D Syndrome Differentiation REVIEW Dr Igor Mićunović Ph.D Outline Syndrome differentiation in TCM is a method to analyses and recognize the syndrome of disease. In other words, it is also a process in which

More information

CMAC311. Session 12. Miscellaneous disorders. Abdominal mass and Myoma (Ji Ju and Zhang Jia) PCOS Endometriosis Chinese Medicine Department

CMAC311. Session 12. Miscellaneous disorders. Abdominal mass and Myoma (Ji Ju and Zhang Jia) PCOS Endometriosis Chinese Medicine Department CMAC311 Session 12 Miscellaneous disorders Abdominal mass and Myoma (Ji Ju and Zhang Jia) PCOS Endometriosis Chinese Medicine Department www.endeavour.edu.au Session Contents o Discuss the TCM aetiology

More information

METABOLIC ASSESSMENT FORM

METABOLIC ASSESSMENT FORM PART II: Please mark the appropriate number on all questions below. 0 as the least/never to 3 as the most/always METABOLIC ASSESSMENT FORM NAME: AGE: SEX: DATE: PART I: Please list your 5 major health

More information

INFERTILITY Giovanni Maciocia

INFERTILITY Giovanni Maciocia INFERTILITY 馬 Giovanni Maciocia 萬 里 INFERTILITY Infertility is defined as the inability to produce offspring in a woman who has been trying for two years with a normal sexual life and, of course, the reproductive

More information

Initial Questions Form

Initial Questions Form Initial Questions Form 422 Broadway Denver CO 80203 (303)921-2993 Please answer as thoroughly as possible. This is detailed so that I can better understand what is going on with you as a whole person.

More information

complexion, fatigue, profuse clear and frequent urination, chronic loose stools, edema in the lower

complexion, fatigue, profuse clear and frequent urination, chronic loose stools, edema in the lower Course: Acupuncture Treatment of Disease 2 Doc: Case Studies Week 1 Infertility and Impotence (really from week 12 last term) Li, Female Age 25 She suffered from infertility for 4 years. She had profuse,

More information

My energy is lower than I would like it to. I feel exhausted after exercising or physical activity.

My energy is lower than I would like it to. I feel exhausted after exercising or physical activity. SYMPTOMS Questionnaire Duplicate your answer across all of the 5 boxes that aren t blocked out. See example ENERGY My energy is lower than I would like it to be. I feel exhausted after exercising or physical

More information

ABOUT THIS MEDICATION What are these drugs used for? Docetaxel is an anticancer drug used to treat cancers in the area of the neck and throat.

ABOUT THIS MEDICATION What are these drugs used for? Docetaxel is an anticancer drug used to treat cancers in the area of the neck and throat. For the Patient: HNAVDOC Treatment of Recurrent or Metastatic Squamous Cell Cancer of the Head and Neck with docetaxel HN=Head and Neck AV=Advanced DOC=Docetaxel ABOUT THIS MEDICATION What are these drugs

More information

Course: Acupuncture Treatment of Disease 2 Date: February 26, 2009 Doc: Case Studies for Quiz 2

Course: Acupuncture Treatment of Disease 2 Date: February 26, 2009 Doc: Case Studies for Quiz 2 Course: Acupuncture Treatment of Disease 2 Date: February 26, 2009 Doc: Case Studies for Quiz 2 This quiz covers: Class 4: Epilepsy Class 5: Headaches and Migraines Class 6: Shingles (Herpes zoster) and

More information

TCM & CONSTIPATION. Provided by AcuPro Academy - Copyright AcuPro Academy 2014 All Rights Reserved

TCM & CONSTIPATION. Provided by AcuPro Academy - Copyright AcuPro Academy 2014 All Rights Reserved TCM & CONSTIPATION Provided by AcuPro Academy - 1 INTRODUCTION TO CONSTIPATION Causes Diet Illnesses Drugs Lack of exercise Emotions 2 TCM PATTERNS FOR CONSTIPATION TCM patterns Symptoms Tx Principles

More information

ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:

ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address: ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: 403.243.8114 Fax: 403.212.0880 Full Name: Address: City: Province: Postal Code: Date of Birth (MM/DD/YYYY): Home Phone:

More information