Consultation Form (General health) Attention: Our website will not store any of your personal information. After completing the form, please click on the 'submit’ button and send the PDF document via email, or take a photo and send it to your therapist. Acupuncture/Chinese Medicine Intake formName Date of birth(Date/Month/Year) Day Month Year Phone NumberOccupation Email Current Medications/Supplements1.Name: Dosage: 2Name: Dosage: 3.Name: Dosage: 4.Name: Dosage: What symptoms would you like to address? Please list your chief complaints1.Major Complaints&Onset Date+ 2.Level of Pain Scale or Uncomfortable Feelings (0 no pain/best feeling - 10 Worst Pain/Feeling)+3.Your expectation from treatment Symptom1. Symptom2. Symptom3. Symptom4. Symptom5. more symptoms.Select the symptoms which you have currently High Blood Pressure High Blood Suger High Cholesterol Diabetes Type 1 Diabetes Type 2 Which muscles/areas are uncomfortable? please tick it.Spine or Head headache neck face(L) face(R) facial paralysis(L) facial paralysis(R) Jaw(L) Jaw(R) middle back(L) middle back(R) lower back(L) lower back(R) sacrum Upper limbs Shoulder Blade(L) Shoulder Blade(R) shoulder joint(L) shoulder joint(R) Upper arm(L) Upper arm(R) elbow(L) elbow(R) forearm(L) forearm(R) hand(L) hand(R) finger(L) finger(R) Thumb(L) Thumb(R) Lower limbs hip(L) hip(R) buttock(L) buttock(R) groin(L) groin(R) hamstring(L) hamstring(R) knee(L) knee(R) Shin(L) Shin(R) Calf(L) Calf(R) ankle(L) ankle(R) foot/feet(L) foot/feet(R) toes(L) toes(R) What sensations do you feel in the mentioned area? pain numbness cramping tingling tightness stiffness Main Symptoms for Zangfu-OrgansLung- Signs& Symptoms Shoulder and neck pain Shortness of breath Cough Asthma Other lung conditions Dry skin Pain in the back of the head Frequent cold and flu Lung - Mental Health& Personality Sadness Grief Lonely Cry Sorrow Heart - Signs& Symptoms Insomnia Heart palpitations Irregular heartbeat pain at the back of the head (+):Tongue ulcer (+):Heart burn (+):Excessive dreaming (+):Shoulder blade pain Heart - Mental Health& Personality Nervous Irritable Anxious Attentive mind Annoyed (-):Small-minded (-):Jealous (+):Impulsive (+):Impatient (+):Angry (+):Stubborn (+):Talkative (+):Frank (+):Passionate (+):Overjoyed (+):Laughing inappropriately Stomach - Signs& Symptoms Stomach bloating or pain Nausea Vomiting Acid reflux Digestive issues (+):Hungry easily (+):Mouth ulcer (+):Forehead headache Liver - Signs& Symptoms Dizziness Eye symptoms Pain at the top of the head (+): Flank pain (+):Breast(nipple) pain (+):Irregular period (+):Tinnitus(high pitch) (+):Migraine (+):Dry eyes (+):Red eyes Liver - Mental Health& Personality Stress Depression Irritability Anger Gall Bladder - Signs& Symptoms Jaundice Gallstones Migraine Gall Bladder - Mental Health& Personality (-):Timidity (-):Lack of confidence (-):Fright (-):Indecisive (-):Poor judgment Spleen - Signs& Symptoms Abdominal distension (-):Tiredness (-):Chronic fatigue (-):Poor appetite (-):Poor digestion (-):Loose stool (-):Diarrhea (-):Weak muscles (-):Pale lips (-):Easy to bruise (-):Excess menstrual blood flow(with tiredness) Spleen - Mental Health& Personality (-):Skeptical (-):Lack of confidence (-):Over thinking (-):Worried Small/Large Intestine - Signs& Symptoms Abdominal pain (+):Gas Bowel movement - Frequency (+)More than every 5days (+)Every 3-4 days (+)Every 2days once a day Twice a day 3-4times/day More than 5 times/day Bowel movement condition Alternating constipation and diarrhea Constipated Dry Normal Soft Sticky Water-like Pass with undigested food Easy to pass Not easy to pass Smelly Not smelly Kidney&Bladder - Signs& Symptoms Frequent urination Profuse urination Painful urination not easy to pass the urine Kidney or Bladder stone (-):Urinary incontinence (-):Tinnitus(Low pitch) (-):Hearing loss (-):Premature gray hair (-):Hair loss (-):Low libido (-):Clear Urine For male: Impotence For male: Premature ejaculation How many times for night urination __ times(from 11pm-7pm)Kidney - Mental Health& Personality Strong willpower (-):Fear (-):Weak willpower (-):Easily startled (-):Poor concentration (-):Poor coordination (-):Memory confusion (-):Poor memory Other health conditionCold/ Heat Upper limb(shoulder/elbow/wrist/hand) cold Lower limb(back/hip/knee/feet) cold Upper limb(shoulder/elbow/wrist/hand) hot lower limb(back/hip/knee/feet) hot feeling cold in the neck and shoulder area General body hot General body cold Sleep HoursPlease enter a number from 0 to 24.Sleep - Light sleep (+)Difficult to fall asleep (+)disturbed sleep (-)Feel sleepy between 9 to 11pm (-)Not refreshed after sleep- kidney deficiency Sleep - Insomnia or wake up at night between 11pm-1am - Gall Bladder 1am-3 am - Liver 3am-5 am - Lung 5am-7am - Large Intestine Throat Dry throat dry mouth (1-3 am-Liver) Dry mouth (3-5am-Lung) Sore throat Itchy Sweating On the head Face hands/palms Feet Chest All over the body Upper back Skin Conditions Dry Itchy Moist Acne(pimples) Eczema Hives Psoriasis Burning Sensation Changing moles/cysts Rashes Dry scalp Bleed easily Diet Bland diet Solid food Spicy food Like oily food Like sweet food Like junk food Dislike oily food More than 2 cups of coffee/day More than 2 cups of green tea/day More than 2 cups of black tea/day too much meat I have Irregular period Periods pain Clots during periods Infertility I have __ times miscarriage historyPlease enter a number from 0 to 20.Section BreakPMS symptoms Grumpy Pimples Headache Dizziness Hot flushes Irritation Anxiety Grief Insomnia Hungry Depression Stress Swollen legs or feet Fatigue Cold lower limbs Lower abdomen pain or cold Lower back pain or cold Breast tenderness Frequent urination Practitioners OnlyPulse,Tongue,Diagnosis,TreatmentPulse: Tongue: Diagnosis: Treatment:Attention: Our website will not store any of your personal information. After completing the form, please click on the 'submit’ button and send the PDF document via email, or take a photo and send it to your therapist. Precautions for Traditional Chinese Medicine: 1. Do not come for acupuncture on an empty stomach to prevent lightheadedness. Symptoms of lightheadedness may include palpitations, dizziness, and sweating. 2. During the treatment, relax your emotions, close your eyes to rest, speak less, and avoid unnecessary body movements to prevent needle bending, dislocation, or stagnation. 3. If there is slight local bleeding or bruising after acupuncture or cupping, you can gently press the area with a sterile cotton swab for 1-2 minutes to promote the absorption of the bruise. Generally, it will resolve on its own without any special treatment. If symptoms persist, apply ice locally for 2 days, then switch to warm compresses on the 3rd day to promote blood circulation. 4. Avoid exposure to cold drafts or air conditioning immediately after acupuncture to prevent exacerbation of symptoms due to sweating and catching a cold. 5. Do not take a bath immediately after acupuncture or cupping, wait at least 2 hours to prevent infection at the needle site. 6. If localized redness or itching occurs after cupping, refrain from scratching. Usually, it will dissipate on its own within a few hours or days. 7. If the skin develops blisters due to prolonged cupping, generally, no specific treatment is needed. If the blister is large, it can be punctured with a sterilized needle to drain the fluid, followed by applying an ointment. "I understand that any treatment given will be explained to me, and I have the right to seek clarification, ask questions, or stop the treatment at any time. I agree to grant access to my clinical notes to any practitioners in this clinic who are involved in my care. If there are any concerns or objections, please let me know. I have read and understood the above information and hereby give my consent to the treatment." HiddenSignature_____________ Name: _____________________________ Date: ______________________________
