Phw Acupuncture Intake Form Page 3
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4CIRCLE the symptoms you currently have;
CHECK the symptoms that you no longer have.
Sleep
Energy
Neurological
difficulty falling asleep
fatigue
anxiety
waking up frequently
weakness or heavy limbs
panic attacks
can’t fall back asleep
drowsiness
depression
bad or vivid dreams
high energy
mood swings
wake up tired
jittery
problems with mental focus
changes in libido
numbness or tingling
tremors
Eyes
Nose
Head
blurry vision
congestion
headaches
redness
sinus infections
migraines
itching
postnasal drip
dizziness
bleeding
ringing in the ears
memory loss
teeth grinding / TMJ
scratchy or itchy throat
Heart
Circulation
Lungs
high blood pressure
cold hands or feet
frequent colds or flu
low blood pressure
Raynaud’s Syndrome
asthma
chest pain
bruising or bleeding
bronchitis
palpitations
swelling or edema
pneumonia
fainting
numbness or tingling
shortness of breath
WOMEN
Digestion
Skin
PMS
heartburn
rashes / hives / itching
heavy periods
nausea
dryness
painful periods
sour belching
acne
irregular periods
ulcers
eczema
in menopause
bloating / gas
psoriasis
hot flashes
abdominal pain
excessive sweating
night sweats
diarrhea or loose stools
night sweats
hysterectomy
constipation
fibroids
gallstones
breast cancer
food intolerances
Urination
number of children _____
diabetes
frequent
difficult
painful
waking to urinate
kidney stones
prostate swelling
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