Consultation Survey Form

Contact Information

      Name  (Required)
    
   Address 
    Line 2 
      City  State  Zip 

 Telephone 
       FAX 
    E-Mail  (Required)

WATER ELEMENT

fatigue
heart palpitations
hearing loss
ringing in the ears
ear infection
shoulder/neck tension
lower back ache
sinus congestion
sciatica/nerve pain
anthelia
muscle spasm
abdominal bloating
general adema
darkness under eyes
headaches
dizziness
emotional instability
aversion to cold
hair thinning or loss
pre-mature aging
change in urinary frequency
night sweats
insomnia
change in sexual energy
bladder infection
kidney stones
cold feet
cold hands
lack of perspiration
weakness of legs/knees
asthmatic cough
rapid weight change

WOOD ELEMENT

migraines
poor eyesight
eye infection
glaucoma
dry eyes
skin eruptions
eczema
shingles
rashes
warts
nervousness
twitching
convulsions
irritability
constipation
hemorrhoids
jaundice
hepatitis
herpes simplex
ulcer
vomiting
chest discomfort
loss of appetite
tendonitis
menstrual irregularity

FIRE ELEMENT

dry scalp
acne
sore throat/tonsillitis
lymphatic swelling
feverish feeling
aversion to heat
bitter taste in mouth
gum problems
nose bleed
tumors, cysts
facial redness
hot hands and feet
excess uterine bleeding
smoker's cough

EARTH ELEMENT

indigestion
flatulence
food allergy
stomach/ulcer
diarrhea
anemia
weakness
halitosis
sores in mouth
heartburn
nausea/appetite loss

METAL ELEMENT

indigestion
bronchitis/asthma
hay fever
shallow breathing
cough
sinus congestion
dry skin
constipation
nasal infection

Indicate all surgeries you have had and give the dates:
Please list any pharmaceuticals you are taking:

If you were to pick one or two emotions which seem to dominate your life, which would they be?:

Do you now undertake or have you undertaken a restricted diet (such as vegetarian, weight loss, high-protein, etc.) Please describe the diet and indicate when:

Please describe briefly your program of physical fitness (type and amount of cardiovascular exercise, moderate exercise, and stretching.

Aside from chronic ailments, most people become ill on occasion and the type of illness is usually the same 9.eg. colds, flu, sore throats, bladder infection, etc. ) What types of illness do you get and roughly how often (during the past five years)?

For female clients Only: Please indicate your experience of the following as on the firs page:

vaginal infection with discharge
yeast infection
ovarian cyst
endometriosis
menstrual cramping
breast lumps
herpes
hemorrhoids
anal fissures
urinary infection
infertility
pelvic inflammatory disease
genital burning
positive PAP smear
excess bleeding
irregular periods
pre-menstrual syndrome

Philosophical or Religious Affiliation?

How and/or from whom did your hear about us?

Medial Doctor or other practitioners?

List any medications or therapies you are presently taking or undergoing?

Have you ever had acupuncture treatments (with whom and approximately how many)?
Have you undergone Herbal Therapy before?

Primary Complaint?

Accompanying Symptoms?

Have you been treated by anyone else for this condition?

Approximately when did you first notice it?

How long has it been occurring?

When and under what circumstances is it worse?

When and under what circumstances does it seem to improve?

Do you have high blood pressure or any heart problem?

Hobbies and Interest?

Additional Questions / Comments:

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