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Gum Problems
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Sore Throat
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Hot Palms/Soles
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Night Sweats
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Heart Palpitations
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Acupuncture
Arthritis
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Sciatica
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Energy Level
Flat
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Fatigue
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Dull
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Clear
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Even
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Emotion / Memory
Substance Use Disorder
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Alzheimer Disease
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LIV/GB (Wood)
Muscle Cramping/Twitching
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Gall Stones
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Eczema
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Soft/Brittle Nails
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Red/Dry/Itchy Eyes
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Indecisive
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LU/LI (Metal)
Dry Mouth/Throat/Nose
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Bronchitis
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Low Resistance to Colds/Flu
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Cough with Sputum
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Dry Cough
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Grief/Sadness
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Treatment Goals
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KID/UB (Water)
Thyroid Problems
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Rapid Weight Change
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Weakness/Pain in Lower Back
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Dark Under Eyes
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Weak Leg/Knees
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Cavities/Tooth Loss
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Bladder Problems
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Excess Worry
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Hearing Problems
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Craving/Avoiding Salty Foods
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Hot Flash/Night Sweating
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Low Sex Drive
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Brain Foggy
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Well Being
Range of Motion
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Hobbies
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Sports
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TMJ (Jaw)
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Locking
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Energy
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What is your energy level upon awakening?
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How long do you sleep on average?
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Do you struggle with insomnia?
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Cluster
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Migraines
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Rebound
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Headaches
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Sinus
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Chronic Daily Headache
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Tension
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Other Headaches
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Reproductive
Pelvic Inflammatory Disease
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Premenstrual Syndrome
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Uterine Disorder
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Breast Disorder
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Pregnancy
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Ectopic Pregnancy
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Gynaecological Conditions
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Endometriosis
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Menopause
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Menstrual Cycle Disorder
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Ovarian Cysts/Tumors
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Hearing
Motion Sickness
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Tinnitus
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Vertigo
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Ear Problems
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Hearing Loss
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Conductive Hearing Loss
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Meniere Disease
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Other Hearing
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Respiratory
Sinus Problem
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Chronic Cough
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Shortness of Breath
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Respiratory Conditions
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Tuberculosis
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Asthma
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Respiratory Tract Infection
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Emphysema
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COPD
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Bronchitis
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Cystic Fibrosis
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Infectious Respiratory Conditions
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Other Respiratory
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Blood
HIV/AIDS
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Hepatitis
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Blood Thinner Medication
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Hypercoagulability
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Haemophilia
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HIV
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Polycythemia
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High Cholesterol
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Thrombosis/Embolism
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Anemia
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Bleeding Disorder
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Gastrointestinal
Digestive Conditions
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Diverticulitis
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Ulcerative Colitis
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Eating Disorder
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Esophageal Disorder
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Crohn's Disease
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Fecal Impaction
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Intestinal Polyps
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Celiac Disease
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Irritable Bowel Syndrome
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Constipation
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Poor Appetite
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Diarrhea
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Stomach Disorder
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Musculoskeletal
Osgood-Schlatter Disease
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Jaw Pain (TMJD)
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Muscular Dystrophy
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Joint Stiffness / Swelling
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Chronic Fatigue Syndrome
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Osteomalacia
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Myasthenia Gravis
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Temporomandibular Joint Dysfunction
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Spasms / Cramps
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Ankylosing Spondylitis
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Torticollis
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Spondylolisthesis
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Baker's Cyst
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Osteoporosis
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Paget Disease
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Degenerative Disk Disease
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Tendonitis/Bursitis
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Bone Disease
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Compartment Syndrome
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Recti Diastasis
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Ehlers-Danlos Syndrome
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Psoriatic Arthritis
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Whiplash
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Osteoarthritis
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Dislocation
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Gout
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Scleroderma
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Sinus Problems
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Carpal Tunnel Syndrome
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Fracture
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Artificial Joints / Special Equipment
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Scoliosis
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Plantar Fasciitis
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Hereditary/Congenital Deformity
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Strain/Sprain
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Broken Bone / Fracture
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Dupuytren's Contracture
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Arthritis
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Joint Injury
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Amyotrophic Lateral Sclerosis (ALS)
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Fibromyalgia
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Bone or Joint Disease
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Chronic Myofascial Pain Syndrome
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Other Musculoskeletal
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Skin
Athletes Foot
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Rosacea
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Athlete's Foot
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Chemical Burn
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UV Burn
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Herpes
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Hypersensitive Reactions
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Hypersensitive Reaction
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Melanoma/Carcinoma
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Bruise Easily
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Pigmentary Disorder
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Melanoma
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Plantar's Wart
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Infectious Skin Conditions
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Acne
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Psoriasis
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Skin Conditions
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Allergic Dermatosis
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Rash
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Skin Irritations
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Other Skin
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Cardiovascular
Aneurysm
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Varicose Veins
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Hyperlipidemia
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Postural Orthostatic Tachycardia Syndrome
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Heart Attack
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Cardiovascular Conditions
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Angina
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Chest Pain
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Pericarditis
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Phlebitis
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Blood Clots
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Atherosclerosis
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Heart Condition
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Raynaud Disease
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Lymphedema
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Cardiac Arrhythmia
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Stroke
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Rheumatic Heart Disease
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