Date of Birth

MM

DD

YYYY

Name *

First Name

Last Name

Phone

(###)

###

####

Past and Present Medical Conditions

Allergies/Asthma

Anemia

Arthritis

Cancer

Chronic Fatigue/Fibromyalgia

Depression/Anxiety/Mental Condition

Diabetes

Digestive Disorder

Eating Disorder

Epilepsy/Seizures

Heart Disease/Stroke

Hemophilia

Hepatitis/Liver Disease

High/Low Blood Pressure

HIV Positive

Kidney Disease

Osteoporosis

Skin Disease

Thyroid Disease

Other

Energy Levels

HIGH

AVERAGE

LOW

EXTREMELY LOW

Stress Levels

LOW

AVERAGE

HIGH

EXTREMELY HIGH

General Symptoms (Acupuncture considers whole body-mind health in its diagnosis and treatment protocols)

PLEASE CHECK ALL THAT APPLY

Fatigue

Sleep issues

Body heaviness

Body feels more cold

Body feels more warm

Poor circulation

Prefer cold drinks

Prefer warm drinks

Cold hands

Cold feet

Water retention or swelling

Recent weight gain or loss

Energy feels low

Sweating issues

Fire Symptoms

Insomnia

Dream-disturbed sleep

Anxiety

Mental/Emotional instability

Palpitations

Chest pains

Speech problem

Restlessness

Hyperactivity

Overly talkative

Unable to concentrate

Poor memory

Startled easily

Faint easily

Wood Symptoms

Depression

Moody

Irritability

Indecisive

Sighing

Nervousness

Distension pain in chest or ribs

Feeling of lump in the throat

Numbness in limbs

Eye problem

Emotionally triggered symptom (eg. headache, poor digestion, insomnia)

Repressed emotions

Easily angered

Dizziness or vertigo

Trembling or shaky hands

Tics or twitching

Muscle cramp or spasm

Tight and stiff muscles

Severe migraines and headaches

Earth Symptoms

Improper eating habits

Poor appetite

Bloating and gas

Belching and hiccup

Abdominal distension and pain

Loose stool

Diarrhea

Constipation

Rectal problem

Muscle weakness

Bleed or bruise easily

Worry a lot

Obsessive thoughts

Nausea and vomiting

Acid reflux

Bad breath

Mouth/gum problem

Cravings

Metal Symptoms

Cough

Wheezing

Shortness of breath

Difficulty breathing

Chest tightness

Nose and throat problem

Repeated sore throat

Swollen glands

Sadness or grief

Cry easily

Foggy or clouded mind

Skin problem

Weak voice

Spontaneous sweating (without heat or exercise)

Water Symptoms

Sore/weak lower back

Sore/weak knee joint

Low sex drive

Overwork or intensive workout

Night sweat

Teeth or hair loss

Ear problem

Exhaustion or afternoon crash

Fears

Addictive patterns

Abuse survivor

Lack motivation or drive

Forgetfulness

Urination problem

Gynecology

Menopausal

Vaginal discharge

Breast lumps

Currently pregnant

Irregular menstruation

Severe menstrual cramps

Trouble conceiving

Gynecological surgeries

Other

Qi, Blood, Fluids

Bearing down or dragging sensation

Organ prolapse

Depression or very low energy

Blurry vision

Dry hair, eyes, mouth or skin

Itching

Feeling of thirst

Little desire to drink

Frequent urination

Feeling of physical restlessness

Often feel bloated

Hot and Cold

Feel more hot than cold

Feel more cold than hot

Feel hot sometimes, cold sometimes

Feel more hot in upper body

Have hot hands or feet sometimes

Have sweating sometimes without exercise

Prefer ice in drinks or cold drinks

Prefer warm drinks

Feel internal or penetrating cold sometimes

Sweat in the cold