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Bleed or bruise easily

VIEWS: 13 PAGES: 2

									                                             ORIENTAL WELLNESS THERAPY

NAME: ________________________________________________ DATE: ___ / ___ / _____

  Please mark an X on the scales and check any boxes of symptoms you have had in the past month.

                                                              TEMPERATURE
                        How warm / cold you feel (not in degrees); relative to other people do you wear more or less layers, etc.

         COLD                                                                                                                       HOT
   Cold hands or feet                  Thirst for cold / hot drinks              Night sweats                        Hot hands, feet, chest
   Chills                               Thirst, no desire to drink              Unusual sweats                      Hot flashes
   Cold “in the bones”                  Absence of thir st                         When_______am/pm                  Hot in afternoon
   Aversion to cold                     Excessive thirst                           Where on body_________            Hot at night

                                                                  MOISTURE
                                               Your overall body moisture (hair, skin, mouth, bowels, etc.)

            DRY                                                                                                                 OILY
   Dry skin                                  Dry mouth                            Edema / Swelling                        Oily skin
   Dry hair                                  Dry lips                             Rashes                                  Oily hair
   Dry eyes                                  Dry throat                           Itching                                 Pimples
   Dry brittle nails                         Dry nose / nose bleeds               Dandruff

                                                                  DIGESTION

    DIARRHEA                                                                                                                CONSTIPATION

BM: How often? _____x / every _____days                        Gas                          Nausea / Vomiting            Dry Stools
Stools keep shape?     Y N                                   Bloating                     Bad breath                   Difficult to pass
 Alternating diarrhea & constipation (IBS)                    Belching                     Poor appetite                Tired after BM
 Indigestion                                                  Heartburn                    Excessive hunger             Foul smelling stools

                                                                    ENERGY

            LOW                                                                                                                 HIGH

 Sudden energy drop          Dependence on caffeine / stimulants                       Dizziness                      Hard to concentrate
Time of day: _____ am/pm      Body / Limbs feel heavy                                   Shortness of breath            Poor memory
 Wired / ungrounded feeling  Body / Limbs feel weak                                    Heart Palpitations
 Fatigue                                                                                Blood pressure High / Low

             SLEEP                                           EMOTIONS                              EYES, EARS NOSE THROAT
# hours per night ______                        What emotion(s) dominate your experience?
                                                                                                    Poor vision             Poor hearing
 Difficulty falling asleep                         Anger                     Grief               Night blindness         Ringing in ears
 Wake ___x/ night @_____am/pm                      Irritability              Depression          Red eyes                Excess earwax
 Wake to urinate                                   Anxiety                   Joy                 Itchy eyes              Sore throat
 Disturbing dreams                                 Worry                     Fear                Spots in front of eyes  Dental problems
 Restless sleep                                    Obsessive thinking        Timid / shy         Sinus congestion        Mouth sores
 Not rested upon waking                            Sadness                   Indecision          Phlegm ( color_______)  Cough

                                                                    MENSES
Age at first menses: ______
Length of full cycle: ______ days                    Heavy periods                     Cramps                      Mood changes
Length of menses: ____ days                          Light periods                      Before bleeding            Fatigue w/ menses
Last menses start date: ____ / ____                  Painful periods                    First day                  Digestive changes w/ menses
# of pregnancies: ____                               Irregular periods                  During period              Midcycle spotting
# of births: ____ premature ____                     Changes in body/psyche            Clots                       Yeast infections
# of abortions / miscarriages: ____                   prior to menstruation (PMS)       Breast tenderness           Bir th control pill (hor monal)
                                           ORIENTAL WELLNESS THERAPY
                                                                                                                     Date:   ___ / ___ / _____
Name:                                                                                             Sex:                Age:
                                                                                                                       Please mark an X on
                                                                                                                       the scales and check
Address:                                                         City:                            State:             Zip boxes
                                                                                                                    any Code: of symptoms
                                                                                                                         you have had in the
                                                                                                                                past month.
Home Phone:                                     Work Phone:                                       Email:



Emergency Contact Name:                                                       Emergency Contact Phone:



Referred By:                                                                  Hav e y ou been treated by Acupuncture or Oriental Medicine Bef ore?


                                                                                    No                   Yes ____/____/____
     Please write in your top 3 health                        Please mark areas of pain or discomfort on the diagrams below
     complaints / concerns in order of
  importance to you. Circle the items that
 make it better or worse and mark on the
    scale from 1-10 the severity of the
condition (1=no symptoms, 10=worst ever)


    1
    When did this star t? __________________ago
    Heat makes it:       better no change wor se
    Cold makes it:       better no change wor se
    Damp weather:        better no change wor se
    Exercise / Activity: better no change wor se

1                                                   10


    2
    When did this star t? _________ __________ago
    Heat makes it:       better no change wor se
    Cold makes it:       better no change wor se
    Damp weather:        better no change wor se
    Exercise / Activity: better no change wor se                                                                                               More on
                                                                                                                                               back…
1                                                   10


 3                                                                             INJURIES & SURGURIES
                                                                Please note what happened to what body area and when it occurred
    When did this star t? ___________________ago
                                                               What___________________________________ _____________When___________
    Heat makes it:       better no change wor se
    Cold makes it:       better no change wor se               What___________________________________ _____________When___________
    Damp weather:        better no change wor se
                                                               What___________________________________ _____________When___________
    Exercise / Activity: better no change wor se
                                                               What___________________________________ _____________When___________
1                                                   10         What___________________________________ _____________When___________

								
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