Acupuncture Intake Form Page 4
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6General Information
O
O
O
Anorexia/Bulimia
Lupus
Mumps
O
O
O
Chronic Fatigue
Lyme disease
Tuberculosis
O
O
O
Chicken Pox
Meningitis
Thyroid Disease
o
Overactive
O
O
Chronic Pain
Scarlet Fever
o
underactive
O
O
Fibromyalgia
Mononucleosis
O
Measles
O
O
Hepatitis ______
Multiple Sclerosis
O
Pneumonia
O
O
HIV
Rheumatoid Disease
O
Tonsillitis
O
O
Herpes/Cold Sores
Rheumatic Fever
O
Cancer: ___________________________________________________________________
O
Other: ____________________________________________________________________
Head, Eyes, Ears, Nose and Throat
O
O
O
Bitter taste
Grinding of teeth
Ringing in ears
o High pitch
O
O
Blurred vision
Goiter
o Low pitch
O
O
Cataracts
Gum problems
O
Sinus issues
O
O
Concussions
Headaches
O
Spots in eyes
O
O
Dry mouth / nose
Hearing aids
O
Swollen glands
O
O
Ear aches
Itchy eyes
O
Teeth issues
O
O
Excess phlegm
Migraines
O
TMJ Syndrome
O
O
Eye pain or strain
Nose bleeds
O
Trigeminal neuralgia
O
O
Facial pain
Poor hearing
O
Watery eyes
O
O
Glasses or contacts
Red or dry eyes
O
Glaucoma
O
Other: ____________________________________________________________________
Respiratory:
O
O
O
Asthma/Wheezing
Cough + Phlegm
Cough + blood
O
O
O
Frequent colds
Emphysema
Difficult breathing
O
O
O
Allergies
Heavy Chest
Tight Chest
O
O
O
Bronchitis
Pneumonia
Short of Breath
O
O
Cough
COPD
O
Other: __________________________________________________________________________
Cardiovascular:
O
O
O
Anemia
Fainting
High blood pressure
O
O
O
Arteriosclerosis
High cholesterol
Irregular heart beat
O
O
O
Easily bruised
Low blood pressure
Pace maker
O
O
O
Poor circulation
Palpitations
Phlebitis
O
O
O
Blood clots
Chest pain
Stroke
O
Heart Disease: ___________________________________________________________________
O
Other: __________________________________________________________________________
Gastrointestinal
O
# Bowel Movements/day___
O
O
O
Normal Stool
Pain after BM
Bad breath
O
O
O
Loose stool
Heartburn/acid reflux
Rectal pain/itching
O
O
O
Constipation
Abdominal pain
Hemorrhoids
O
O
O
Diarrhea
Appendicitis
Hernia
O
O
O
Undigested food in stool
Bloating
Liver Disorder
O
O
O
Mucous in stool
Celiac Disease
Ulcer
o H. Pylori Negative
O
O
Blood in stool
Gas
o H. Pylori Positive
O
O
Strong odour
Hiccups
o Not Tested
O
O
Pain before BM
Nausea/vomiting
O
Other: __________________________________________________________________________
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