Condition #2: What is the next important condition you would like help with, and how long ago did it begin?:

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Transcription:

NAME _ Please take the time to fill this form out completely. The more information we have, the better we can assist you, and will make better use of your initial visit. What is the main problem you would like help with, and how long ago did it begin?: Condition #2: What is the next important condition you would like help with, and how long ago did it begin?: Condition #3: What is the next important condition you would like help with, and how long ago did it begin?:

Condition #4: What is the next important condition you would like help with, and how long ago did it begin?: Conditions #5: List any remaining conditions you would like help with, and how long ago did they begin?: Have you been given a diagnosis for this condition(s) and what is it? Are you taking: prescribed drugs / over-the-counter drugs recreational drugs vitamins / minerals / supplements / herbs homeopathic remedies Please list: What are your typical work and recreational activities (ie. computer, lifting, sitting or standing long periods, running, skiing, etc.) Please describe your typical foods and beverages: (ie: dairy? protein? fruit? veggies? coffee? water? alcohol?)

Please circle any conditions you have had, and note how recently: General - Addictions (list:) - AIDS / HIV / ARC - Allergies (list:) - Aversion to: cold / heat / wind / damp - Bleed or bruise easily - Cancer (type:) - Candida / yeast infections - Chills - Chronic viral, bacterial, or parasitic infection - Fevers - Fatigue / Chronic Fatigue Syndrome - Hepatitis - Hot palms / soles (esp. at night) - Organ or gland malfunctions (list:) - Past history of IV drug use - Poor sleep / insomnia / dream-disturbed sleep - Sensitive to light / sound / easily startled - Smoking - Substance abuse - Sudden energy drop Time of day? - Surgeries / Major dental work: - Thyroid disease - Traumas, major (physical or emotional): - Use of products containing Aspartame, Nutrasweet, or Equal - Use of long-term prescription drugs (please list): Cardiovascular / Chest - Anemia - Blood clots - Chest pain / pressure - Cold hands, feet - Embolisms, thromboids, aneurism - Fainting - Heart Disease - High blood pressure: Cause? - High cholesterol - Low blood pressure - Palpitations / irregular heart beats - Swelling of feet, hands - Varicose veins - Other Ears - Discharge from ear - Earaches - Poor hearing - Ringing in ears Eyes - Blind field - Blurry vision - Cataracts - Color blindness - Discharge from eyes - Excessive tearing - Eye dryness - Eye pain - Eye strain - Glasses / contacts - Night blindness - Poor vision - Spots in front of eyes (floaters) Gastrointestinal - Abdominal pain or cramps - Anorexia / Bulimia - Antacid use, regular (Tums, etc.) - Bad breath - Belching - Black stools - Blood in stools - Change in appetite - Constipation - Cravings - Diabetes - Diarrhea / Loose stools / watery stools - Gas - Gallstones - Heartburn - Hemorrhoids - Hypoglycemia - Indigestion - Irritable Bowel Syndrome - Lactose intolerant - Laxative use, regular - Nausea - Nutritional deficiencies - Peculiar tastes or smells - Poor appetite - Rectal pain - Strong thirst (cold or hot) - Thirst, no desire to drink - Vomiting - Weight gain - Weight loss - Other

Head / Mouth / Throat - Cold sores (herpes) - Concussions - Dizziness / Fainting spells - Facial pain - Headaches When: Where: - Lump in throat - Migraines - Sores on lips or tongue - Sore throats, chronic - Teeth problems - TMJ / Grinding / Jaw clicks - Other Musculoskeletal - Arthritis - Bursitis / Tendinitis - Carpal Tunnel - Dislocations - Fibromyalgia - Fractures - Herniated disk - Inflammation - Muscle cramping - Muscle pain / soreness Back: low / middle / upper / sacrum Elbow Foot / ankle / leg / thigh Hand / wrist / lower arm / upper arm Hip Knee Neck Shoulder - Muscle weakness - Osteoporosis - Pinched nerves - Whiplash Neuropsychological - Anger / Anxiety / Fear / Sadness / Irritability - Balance, lack of - Coordination, lack of - Depression - Loss of control / violence potential - Memory, poor - Numbness, areas of - Seizures - Sleep disorder - Stress, easily susceptible to - Tremors - Vertigo - Weakness - Worry - Other Nose - Nasal drainage - Nose bleeds - Sinus congestion OB Gyn / Pregnancy # pregnancies: # births: # premature births: # miscarriages : # abortions: Age at first menses: Period between menses: Durations of menses: First date of last menses: Menopause: Age Year Date of last pap: Results: Type of Birth Control - Bleeding after intercourse - Breast lumps - Changes in body / emotions prior to period - Clots - Flow: light / medium / heavy - Irregular periods - Nipple discharge - Painful periods - Vaginal discharge Family History: Alcoholism Cancer High blood pressure Other Allergies Diabetes Seizures Asthma Heart disease Stroke If there are any health care providers you wish me to consult with, please list below:

Respiratory - Asthma / wheezing - Bronchitis - Cough - Coughing blood - Difficulty breathing lying down - Pain with deep breath - Phlegm (color: ) - Pneumonia - Shortness of breath Skin and Hair - Acne - Change in hair or skin - Dandruff - Edema (swelling) Where? - Eczema - Hair loss - Hives - Itching - Moles, recent changes - Oozing on skin lesion - Ulcerations - Rashes / Non-healing rash or lesion - Sweat easily / Night sweats / Hot flashes - Other Uro-genital - Blood in urine - Change in sexual drive - Color of urine: - Decrease in flow - Dribbling - Frequent urination - Genital herpes - Impotence - Incontinence - Kidney stones - Night urine How often: - Pain or burning on urination - Urgency to urinate - Sores on genitals - Viral / bacteria infections (list:) Any problems with using Eucalyptus, Menthol, Camphor, or Wintergreen? YES NO Therapy will not be administered to anyone under the influence of alcohol or other drugs. Cupping will not be administered to anyone with disease of the circulatory or lymphatic systems (ie. most cancers), or in any other cases where conditions contraindicate, unless permission has been obtained from your physician and you are willing to sign a release form. --------------------------------------------------------------------------------------------------------------------------------------------- I have read and filled out the above information to the best of my knowledge. I am responsible for making my practitioner aware of any changes in my conditions on an on-going basis before any therapy is administered. Signed Dated How did you hear about this clinic?

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