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Emergency Contact
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Doctor
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Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Conditions
TMJ (Jaw)
Locking
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Difficulty Opening Jaw
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Difficulty Chewing
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Clenching
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Morning Stiffness
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Ear Ringing
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Ear Stuffiness
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Jaw Pain
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Ear Pressure
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Clicking
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Ear Blockage
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Energy Level
Even
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Fatigue
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Vibrant
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Dull
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Low
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Agitated
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Chaotic
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High
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Clear
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Flat
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Well Being
Sports
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Flexibility
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Range of Motion
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Hobbies
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Interests
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Exercise
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Energy
Do you struggle with insomnia?
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Does your energy fluctuate?
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How long do you sleep on average?
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Is your energy constant?
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What is your energy level upon awakening?
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When is your energy highest?
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When is your energy lowest?
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HT/SI (Fire)
Aversion to Heat
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Acupuncture
Fatigue
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Numbness
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Emotion / Memory
Anxiety Disorder
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Stress
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Female Health
Irregular Periods
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Area of Complaint
Left Side of Neck
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Right Side of Neck
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Left Side of Upper Back
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Right Side of Upper Back
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Left Side of Mid Back
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Right Side of Mid 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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Right Leg
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Left Hip
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Right Hip
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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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Headaches
Cluster
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Rebound
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Sinus
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Migraines
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Chronic Daily Headache
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Headaches
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Tension
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Immune
Allergies
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Cancer
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Other Immune
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Neurological
Parkinsons
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Stroke
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Herniated Disc
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Loss of Sensation
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Sciatic Pain
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Vertebral and Spinal Cord Injury
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Multiple Sclerosis
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Chronic Pain Disorder
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Brain Injury
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Numbness
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Shingles
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Dizziness
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Cerebral Vascular Accident (Stroke)
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Burning
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Seizure Disorder
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Tingling
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Stabbing
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Hearing
Hearing Loss
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Ear Problems
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Skin
Allergic Dermatosis
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Bruise Easily
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Athletes Foot
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Skin Conditions
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Chemical Burn
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Skin Irritations
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Hypersensitive Reactions
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Pigmentary Disorder
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Psoriasis
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Infectious Skin Conditions
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Rash
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Melanoma
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Acne
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Family History
Respiratory
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Cardiovascular
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Arthritis
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Musculoskeletal
Strain/Sprain
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Amyotrophic Lateral Sclerosis (ALS)
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Arthritis
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Tendonitis/Bursitis
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Dislocation
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Osteoarthritis
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Osteoporosis
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Carpal Tunnel Syndrome
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Fracture
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Artificial Joints / Special Equipment
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Plantar Fasciitis
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Joint Injury
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Whiplash
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Chronic Fatigue Syndrome
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Psoriatic Arthritis
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Jaw Pain (TMJD)
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Sinus Problems
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Scleroderma
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Fibromyalgia
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Scoliosis
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Other Musculoskeletal
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Reproductive
Menopause
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Ovarian Cysts/Tumors
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Gastrointestinal
Poor Appetite
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Digestive Conditions
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Eating Disorder
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Emotion / Mood
Stress Response and Coping Strategies
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Overall mood and energy level
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Rate the stress in your life (1-10)
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Anxiety
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Depression
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Fear
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Grief
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Negative Self-Talk
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PTSD
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Anger
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Sadness
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