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May we leave a message if we call?
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May we include in E-newsletter?
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Occupation
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Employer
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Marital Status
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Any Children?
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If yes, How many
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Person responsible for your account?
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How did you hear about us?
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Did someone refer you?
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If yes, who referred you?
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Have you received acupuncture before?
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Name your primary care physician?
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Address
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Phone Number
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Date last visited
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Select if any of the following are true?
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Reason for visit today?
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How long you had this condition today?
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Any other condition(s) you wish to address?
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How long you had this condition today?
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PAIN/HEADACHES
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New Field
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Rate your pain?
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Describe your pain?
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Other
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Therapies/meds/foods that improves pain/headache
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What makes the pain worse?
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Review of systems
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Spleen and stomach
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Spleen Qi Deficiency
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Spleen Yang Deficiency
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Spleen not controlling the blood
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Spleen Qi Collapse
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Dampness (Damp Heat orDamp Cold)-in Middle Jiao
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In Lower Jiao
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Stomach Yin Deficiency
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Stomach Fire
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LUNG
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Lung Qi Deficiency
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Phlegm in the Lungs
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Wind cold / Wind heat
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Lung Yin Deficiency
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Liver
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Liver Qi Stagnation
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Liver Invading the Spleen or Stomach
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Liver blood Stasis
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Liver fire
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Damp Heat in the Liver and Gallbladder
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Cold Stagnation in the Liver Channel
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Liver Blood Deficiency
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Where do you have muscle spasm or cramps
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Liver Yang Rising
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Liver Wind
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SKIN
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KIDNEYS
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Kidney Yin Deficiency
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Kidney Yang Deficiency
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Kidney Qi Deficiency
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Kidney and Liver yin Deficiency
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Kidney and Heart not communicating
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Kidney and Spleen yang Deficiency
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Lung and Kidney Disharmony
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HEART
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Heart Qi Deficiency
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Heart Yang Deficiency
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Heart Blood Deficiency
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Heart Yin Deficiency
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Heart Fire
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Phlegm-Fire Harassing the Heart
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FEEL about the following areas of your life?
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Significant Other
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Comments
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Family
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Comments
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Diet
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Comments
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Sex
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Comments
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Self
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Comments
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Work
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Comments
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Exercise
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Comments
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Sleep
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Comments
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Spirituality
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Comments
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Any other problems you would like to discuss
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