Name

ageaddress

telephone 

e-mail       

occupation

current chief complaint(s)please give details.

current medications (dosage and length of time)

A complete health history is essential, please fill out the two questionnaires. A traditional   Chinese "asking song", and a western metabolic screening questionnaire.

Traditional Chinese Asking Song " Describe your experience with the following..."

Hot or Cold           

Perspiration           

Appetite                  

Thirst                        

Taste(s)                     

Defecation                

Urination                   

Pain                            

Sleep                          

Menses                      

Metabolic Screening Questionnaire

Rate each of the following symptoms based upon your typical health profile for the last 30 days.

Digestive Tract

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe nausea or vomiting

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe diarrhea

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe constipation

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe bloated feeling

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe belching or passing gas

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe heartburn

Ears

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe itchy ears

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe earaches,ear infections

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe drainage from ear

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe ringing in ears, hearing loss

Emotions

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe mood swings

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe Anxiety, fear or aggressiveness

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe Depression

Energy/Activity

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe Fatigue, sluggishness

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe apathy, lethargy

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe hyperactivity

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe restlessness

Eyes

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe watery or itchy eyes

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe swollen,reddened or sticky eyelids

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe bags or dark circles under eyes

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe blurred or tunnel vision

Head

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe headaches

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe faintness

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe dizziness

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe insomnia

Heart

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe irregular or skipped heartbeat

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe rapid or pounding heartbeat

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe chest pain

Joints/Muscles

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe pain or aches in joints

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe arthritis

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe stiffness or limitation of motion

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe pain or aches in muscles

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe feeling of weakness or tiredness

Lungs

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe chest congestion

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe asthma, bronchitis

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe shortness of breath

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe difficulty breathing

Mind

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe poor memory

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe confusion, poor concentration

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe poor physical coordination

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe difficulty in making decisions

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe stuttering or stammering

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe slurred speech

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe learning disabilities

Throat/Mouth

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe chronic coughing

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe gagging, frequent need to clear throat

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe sore throat, hoarseness, loss of voice

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe swollen or discolored tongue, gums,lips

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe canker sores

Nose

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe stuffy nose

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe sinus problems

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe hay fever

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe sneezing attacks

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe excessive mucus formation

Skin

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe acne

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe hives, rashes or dry skin

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe hair loss

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe flushing or hot flashes

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe excessive sweating

Weight

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe binge eating/drinking

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe craving certain foods

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe excessive weight

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe compulsive eating

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe water retention

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe underweight

Other

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe frequent illness

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe frequent or urgent urination

never occasionally,not severe occasionally, severe frequently, not severe frequently,severe genital itch or discharge