This is the information that will help me to determine the best way to treat you.
Please print and fill out the form below and bring it with you to your first appointment. OR Click and print out either the PDF file or the Word File from the links below.
Please Check the appropriate boxes and add any pertinent information to this form and click the submit button.
Patient Symptoms and Evaluations
Check the box when you experience the symptom
Please indicate symptoms that are current (c) or past (p)
When answering the following please rate with a number
#1 occasionally, mildly - # 2 frequently, moderately severe - # 3 disabling or persistent
Headache and Dizziness Headaches that have:
radiating pain
dull pain
sharp pain
Location
forehead
occipital (base of the skull)
at the temples
top of head
Dizziness
yes no
how frequent? ______________
Blood pressure_______ mmhg
Hair and Skin
Hair falls out frequently
premature graying
dry hair
oily hair
skin rashes
dry skin
easily bruised
acne
other
Ears Nose Throat and Mouth
history of earaches
tinnitus/ ringing of the ears
high pitched
low pitched
abnormal ear discharge
vertigo/ difficulty keeping balance
nosebleeds
history of sore throats
frequently blow your nose (even when you aren’t sick)
swollen glands 2
Eyes and Mouth
eye pain / swelling
blurry vision / visual spots
red, itchy eyes
do you clench your jaw?
experience foul breath
bleeding in the gums
Chest and Cough
dry cough
with phlegm
shortness of breath / wheezing
asthma
frequent colds
burning chest pain
rapid heart beat
distending/ chest fullness
chest tightness
palpitation / feel your heart beat abnormally
Digestion
belching nausea
indigestion esophageal reflux
hiccup vomiting gas
Stomach pain
burning distending (moves around)
dull pain
pain after eating
Appetite
decreased
increased
Bowel Movement: frequency ____
Constipation:
yes
dry stool
difficult to expectorate
Diarrhea
yes
watery stool
foul odor stool
abdominal pain following stool
undigested food in the stool
at dawn
Urination
Frequency( relative to intake)
low (6 per day)
high (8 per day)
colour: clear 3
dark
Painful urination yes no
Difficulty holding yes no
Incontinence ( leaking) yes no
Do you experience, Enuresis( inability to control urine especially during the night)
yes no
Muscles and Joints please circle and indicate the area of pain and swelling.
heavy sensation over body and limbs
low back pain
knee soreness
numbness or tingling
Body Temperature:
alternating fever and chills
dislike of heat
dislike of cold
night sweats
daytime sweats
Sexual Energy
increased
decreased
Female Section :
Menopause
yes no
If yes, when was your last cycle?____________
Menstruation:
When was you first day of your last cycle? ___________
How many days of bleeding is your cycle? _____________
Are your cycles:
regular
early
delayed
irregular 4
Quantity
heavy
light
color
bright/ fresh blood red
light pink red dark/ black red
property
stringy clots
thick with (quarter sized clots)
Do you have cramps
yes no
Do you take medication or herbs for the pain? ______________
Have you been diagnosed with amenorrhea (absence of period) yes no
When was your last cycle?____________
Do you have spotting (in between periods) yes no
Do you have Leukorrhea (period with white/yellow discharge yes no
Pregnancy
Are you pregnant?
yes no
Are you trying to get pregnant? ________
How many children do you have? ________
Did you have normal deliveries? yes no
Any miscarriages yes no
General Information
Energy level
low
high
Sleep
difficulty falling asleep
Wakes frequently through the night
Weight
loss
gained
Thirst
usually
seldom
Do you experience prominent emotions of ….
sadness
anger/frustration
depression
other
Do you experience anxiety?
Thank you for taking the time to fill out these forms, they will help me see a clear picture of your
overall diagnosis for Traditional Chinese Medicine.
Muriel Hill
Acu - Pro Health and Healing 1221 Parkdale Creek Gardens Victoria, B C V9B 4G9
