Acupuncture
Acupuncture
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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
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Additional Info
Conditions
HT/SI (Fire)
Skin Rash
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Cysts/Tumor
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Hot Palms/Soles
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Sore Throat
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Dry Scalp
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Insomnia/Sleep Problems
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Thirst
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Ear Infection
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Itchy/Burning Skin
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Vivid Dreams
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Easily Startled
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Lack of Joy in Life
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Excess Joy
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Lymph Swelling
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Aversion to Heat
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Facial Redness
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Night Sweats
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Bitter Taste in Mouth
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Gum Problems
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Nose Bleed
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Restlessness/Agitation
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Chest Pain
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Heart Palpitations
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Treatment Goals
Stress Relief
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Support in Healing/Recovery
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Health Advice for Healing
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Improve Lifestyle
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Improve Symptoms
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Improve Well Being
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Pain Relief
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Rehabilitation
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Other
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LU/LI (Metal)
Grief/Sadness
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Snoring
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Low Resistance to Colds/Flu
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Nasal Discharge
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Post-Nasal Drip
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Asthma/Allergies
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Shortness of Breath
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Bronchitis
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Sinus Trouble
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Cough with Sputum
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Skin Rashes/Hives
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Dry Cough
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Dry Mouth/Throat/Nose
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Sneezing
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LIV/GB (Wood)
Fullness Below Ribs
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Joints/Neck/Shoulder Pain
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Teeth Clenching at Night
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Gall Stones
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Muscle Cramping/Twitching
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Tension
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Blurred Vision
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Headaches/Migraines
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Poor Circulation
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Visual Problems
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Depression/Stress
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Dizziness
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Herpes Simplex
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Red/Dry/Itchy Eyes
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Eczema
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Indecisive
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Ringing in Ears
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Emotional Eater
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Insomnia 11pm-3am
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Shingles
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Feeling of Lump in Throat
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Intermittent Mild Fever
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Shoulder/Neck Tension
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Irritability/Anger
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Soft/Brittle Nails
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KID/UB (Water)
Decrease Bone Density
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Loss of Hair
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Weakness/Pain in Lower Back
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Emotional Instability
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Low Sex Drive
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Excess Worry
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Poor Memory
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Fear
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Rapid Weight Change
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Bladder Problems
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Feel Cold Easily
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Tendency to Gain Weight
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Brain Foggy
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Hearing Problems
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Thyroid Problems
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Craving/Avoiding Salty Foods
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Hot Flash/Night Sweating
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Urinary Problems
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Dark Under Eyes
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Lack of Bladder Control
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Weak Leg/Knees
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Health Questions
Hearing Impairment
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Heart Attack
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Heart Condition
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Pacemaker
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Asthma
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Past Heart Surgery
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Concussion
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Stroke
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Congenital Heart Defect
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Epilepsy
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SP/ST (Earth)
Easily Bruising & Bleeding
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Indigestion/Heartburn
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Abdominal Pain
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Edema (Swelling)
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Insulin Sensitivity
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Bad Breath
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Fatigue/Worse After Eating
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Muscles Feel Tired Often
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Nausea/Vomiting
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Constipation
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Gas/Belching
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Over-Thinking
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Crave Sweets
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Hard to Get Up In AM
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Decreased/Increased Appetite
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Heaviness Anywhere in Body
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Diarrhea
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Hemorrhoids
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Difficulty Digesting Fats/Oils
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Hypoglycemia
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Infectious
Pneumonia
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Strep
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Epstein Barr
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Lyme Disease
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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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Emotion / Memory
Alzheimer Disease
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Anxiety Disorder
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Mood Disorder
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Stress
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Substance Use Disorder
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Female Health
Hysterectomy
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Menopause
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PMS
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Severe Menstrual Pain
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Infertility
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Breast Cancer
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Ovarian Cancer
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Osteoporosis
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Current Menopausal Concerns
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Area of Complaint
Neck
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Upper Back
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Mid Back
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Low Back
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Abdomen
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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 Foot
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Right Foot
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Sacrum
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Headaches
Chronic Daily Headache
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Cluster
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Headaches
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Migraines
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Sinus
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Tension
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Endocrine
Hyperthyroidism
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Hypothyroidism
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Diabetes
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Other Endocrine
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Neurological
Numbness
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Cerebral Palsy
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Parkinsons
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Chronic Pain Disorder
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Sciatic Pain
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Dizziness
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Sleeping Disorders
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Epilepsy
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Stroke
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Fatigue
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Tingling
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Fibromyalgia
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Twitching of Face
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Bell's Palsy
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Herniated Disc
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Multiple Sclerosis
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Carpal Tunnel
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Gastrointestinal
Acid Reflux
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Intestinal Gas/Bloating
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Celiac Disease
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Irritable Bowel Syndrome
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Constipation
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Ulcerative Colitis
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Crohn's Disease
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Diarrhea
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Digestive Conditions
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Diverticulitis
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Gastroparesis
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Reproductive
Enlarged Prostate
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Gynaecological Conditions
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Menstrual Cycle Disorder
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Ovarian Cysts/Tumors
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Pelvic Inflammatory Disease
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Endometriosis
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Musculoskeletal
Spasms / Cramps
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Gout
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Spondylolisthesis
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Joint Injury
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Strain/Sprain
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Osteoarthritis
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Osteoporosis
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Temporomandibular Joint Dysfunction
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Arthritis
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Plantar Fasciitis
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Tendonitis/Bursitis
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Carpal Tunnel Syndrome
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Psoriatic Arthritis
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Whiplash
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Chronic Fatigue Syndrome
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Sinus Problems
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Degenerative Disk Disease
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Fibromyalgia
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Family History
Arthritis
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Cancer
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Cardiovascular
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Diabetes
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Respiratory
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Allergy
Environmental
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Food
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Latex
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Medical
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Emotion / Mood
Anger
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Negative Self-Talk
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Anxiety
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Other Emotions
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Confusion
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Overall mood and energy level
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Depression
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Physical Abuse History
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Despair
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PTSD
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Fear
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Rate the stress in your life (1-10)
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Grief
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Sadness
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Mental Abuse History
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Stress Response and Coping Strategies
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