wellness questionair › wp-content › uploads › 2019 › 06 › ... · tpa wellness * 43422...

PATIENT NAME: DATE:

Check all that apply based on what you are CURRENTLY experiencing

CHILL AND FEVER

Averson to cold & feeling chilly WC/WH

Low grade fever (afternoon only) YIN-DEF

Constant low grade fever DAMP-HEAT

Fever in the middle of the night YIN-DEF

Chills & fever INTERMEDIATE

SWEATING

Head only STOMACH HEAT/DAMP HEAT

Arms & legs ST/SP DEF

Hands only LUNG QI DEF/NERVOUSNESS

Whole body LUNG QI DEF

Palms, soles & chest YIN DEF

Oil sweat on forehead YANG COLLAPSE

Sweating during day/night YANG DEF/YIN DEP (DAMP HEAT)

Oily sweat YANG DEF SEVERE

Sticky sweat YIN CALLAPSE

Yellow sweat DAMP HEAT

HEAD & BODY

HEADACHES

During the day QI/YANG DEF

Night time headaches BLOOD/YIN DEF

nape of neck headache TAI YANG (EX WC/KID DEF)

forehead headache YANG MING (ST HEAT/BLOOD DEF)

headache at temples/side SHAO YANG (EX WC/WH, LIV/GB FIRE)

Top of head JUE YIN (LIV BLOOD DEF)

Whole head EX WC

Heavy feeling DAMPNESS/PHLEGM

Inside the head, hurting brain KID DEF

Distending/throbbing headache LIV YANG RISING

Boring, like a nail BLOOD STASIS

Aggravated by fatique QI DEF

BODY PAIN

Pain all over w/tiredness QI/BLOOD DEF

After birth-dull pain BLOOD DEF

After birth-arms/shoulders LIV QI STAG

All muscle pain with hot sensation ST. HEAT

Pain with feeling heaviness DAMPNESS

FOOD & TASTE

TASTE

Bitter taste LIV/HEART FIRE

Constant bitter taste LIV FIRE

Sweet SP DEF/DAMP HEAT IN THE SP/ST

Sour FOOD RETENTION/LIV ST. DISHARMONY

Salty KID YIN DEF

Pungent LUNG HEAT

Lack of taste SP DEF

WELLNESS QUESTIONAIR

FOR DOCTORS USE ONLY

TPA WELLNESS * 43422 Business Park Dr., Temecula CA 92590 * (951) 693-5555

STOOL

CONSTIPATION

Acute w/thirst, dry yellow tongue ST HEAT/SI HEAT

With small,bitty stools like goat's LIV QI STAG-HEAT ST

With abdominal pain INTERNAL COLD & YANG DEF

With dry stools, no thirst YIN DEF (KID/ST)

Stools not dry, butt difficult to pass LIV QI STAG

Constipation and diarrhea LIV QI STAG INVADING SP

DIARRHEA

With pain LIV/HEAT

Foul smell HEAT

Absence of smell COLD

Chronic SP/KD YANG DEF

Every day/evening morning KID YANG DEF

With abdominal pain INTERIOR COLD IN INTESTINES

With mucus in stools DAMP IN INTESTINES

With mucus and blood DAMP HEAT IN INTESTINES

Loose stools with undigested food SP QI DEF

With burning sensation in anus HEAT

Not loose/frequent diarrhea SP/ST QI DEF, SP QI SINKING

Black/dark stools BLOOD STASIS

Loose stools with borborygmus (stomach rumbling) SP DEF

Borborygmus with abdominal distension LIV QI STAG

Flatulence LIV QI STAG

Flatulence with foul smell DAMP HEAT IN SP/ST HEAT

Flatulence without smell INT COLD D/T SP YANG DEF

URINE

Urinary incontinence KID DEF

Retention of urine DAMP HEAT IN UB

Difficulty urinating UB DAMP HEAT/KD DEF

Frequent and copious urination ID DEF

Frequent and scanty urination QI DEF

PAIN

Pain before urination QI STAG IN LOWER BURNER

Pain during urination HEAT IN UB

Pain after urination QI DEF

COLOR

Pale color COLD

Red/yellow/dark color HEAT

Cloudy/Murky/Thick DAMP IN UB

Abundant clear & pale BIAO

AMOUNT

Clear copious amount KD QI DEF/UB DYSFUNCTION

Large amount of urine KID YANG DEF

Scanty urine KID YIN DEF

Scanty yellow urgent painful urination DAMP HEAT IN UB


SLEEP (Insomnia)

Hard time falling asleep HEART BLOOD DEF

Waking many times KID YIN DEF

Dream-distrubed sleep LIV/HEART FIRE

Restless sleep with dreams FOOD RETENSION

Waking up early morning, can't get back to sleep GB DEF

LETHARGY

Feeling sleepy after eating SP QI DEF

lethargy and dizziness PHLEGM

Extreme lethargy KID YANG DEF

EYES

Like needle pain & redness of eye(s) FIRE POISON IN HT

With swelling, redness of eye W-H INVASION/LIVER FIRE

blurry vision & floaters LIVER BLOOD DEF

Photophobia LIVER BLOOD DEF

Pressure in the eyes KID YIN DEF

Eye dryness LIV/KID YIN DEF

THIRST AND DRINKING

Absence of thirst SP/ST COLD

Thirst with no desire to drink DAMP HEAT

Thirst of warm liquids ST/KID YIN DEF

Thirst for cold liquids / warm liquids HEAT/COLD


Treatment(s) you have received for this condition:

1) 2)

SYMPTOMS

NOTE: For each symptom you currently have, rate it's severity from 1-10 (10 being worst).

Leave blank if NOT APPLICABLE. Circle choice if two choices are given.

LIVER / GALLBLADDER Poor memory Low resistance to colds/FLU

Irritability/Anger Hair loss Sneezing

Depression/Stress Hearing problems Mild fever comes & goes

Headaches/Migraines Cavities Smokes cigarettes

Visual Problems Fear Emphysema

Red/Dry/Itchy Eyes Hot flash/night sweats Bronchitis

Gall stones Do you crave "salty"? Constipation

Dizziness HEART/SMALL INTESTINE IBS

Blurred Vision Heart palpitations Colitis/spastic colon

Feeling of Lump in throat Chest pain Diarrhea

Clenching of teeth at night Insomnia/sleep problems Do you crave "Pungent"?

Muscle cramping/twitching Easily startled SPLEEN/STOMACHTension Restlesness/agitation

Joints/Neck/Shoulder Vivid dreams

Pain/Tight Lack of joy in life

Poor Circulation Do you crave "bitter"?

Soft/Brittle Nails LUNG/LARGE INTESTINEEmotional eater Bloody cough

Bad taste in mouth Dry cough

Bad breath Cough with sputum

Do you crave "sour"? Nasel discharge (Circle color)

KIDNEY/URINARY BLADDERUrinary problems

Bladder infection

Dropped bladder

Incontinence

Weakness/pain in lower back

Decreased bone density

Feel cold easily

Cold hands

Cold feet

Low sex drive/libido

Post nasal drip (circle color)

Sinus infection/congestion

Itchy,red or painful throat

Skin rashes/hives

snoring

Grief/sadness

Shortness of breath

Allergies/asthma

Excess sexual desire

Heaviness anywhere in the

body Energy on a scale of 1-10

(1, low 10, high)

Hard to get up in the morning

Muscles feel tired often

Edema(swelling)

Hands Feet

Easily bruising & bleeding

Bad breath

Nausea/vomiting

Difficulty digesting fatty foods

Gas/belching

Hemorrhoids

Diarrhea

Abdominal pain

Indigestion/heartburn

Over thinking

Tendency to gain weight

Brain foggy

Do you crave "sweet"?

MEDICATIONS - Please list all prescription medications you use. Include those which you may only use

ocassionally. Remember inhalers, eye drops, nose sprays, and topical creams. Note: If you need inhalers,

eye drops, nose sprays, and topical creams. NOTE: If you need more space, use page 7 under "Notes/Anything Else".

PRESCRIPTION NAME PURPOSE

HOW LONG ON

MEDICATION DOSE

TAKEN HOW

OFTEN LAST DOSE


White Yellow Green

White Yellow Green

On a scale of 1-10, rate your commitment to get rid of the problem(s) and feel better.

Have you had acupuncture treatments before?

If yes, who treated you and where?

Any concerns or fears about the needles?

What are your goals of your acupuncture visits?

1)

2)

3)

YOU FATHER MOTHER SPOUSE

AGE

AIDS/HIV

Alcohol Abuse

Anxiety

Anorexia/Bulimia

Arthritis

Asthritis

Asthma/Hay Fever/Allegy

Back Trouble

Bursitis

Cancer

Constipation

Depression

Diabetes

Digestive Trouble

Headaches

Heart Trouble

Liver Trouble

Migraine

Neck Pain

Thyroid Disorder

Suicidal Tendencies

Tobacco

Weight Problem

Other Emotional Problems

Other

If any of the above family members are deceased, please list their age at death and cause.

SURGERIES: (Including removal of wisdom teeth)

Date or Age Type of Surgery Location of Scar

PERSONAL MEDICAL & FAMILY HEALTH HISTORY

Please indicate which of the below health issues you or your family members are currently experiencing or experienced in the past. If experiencing currently, Place a C in the square, If experienced in the past, Place a P in the square. Leave blank those that

do not apply.

BROTHER(S) SISTER(S) CHILDREN

If yes, what?


Hysterectomy - Ovaries removed? Yes No

Could you be pregnant now? Yes No

Number of: Pregnancies BirthsMiscarriages Abortions

Birth Control:None Spermicides IUDBirth Control Pills Barriers

Premenstrual syndrome (mark all that apply)Fluid retention Cravings Tender/weepyFluctuating emotions Fatigue IrritabilityTenderness in breasts Depression Loose stool

Yes NoNumber of days from one menstrual cycle to the next?

Moderate Light

Post-menopausal bleeding When did your last period start?Number of days bleeding lastsDescribe menstrual flow:

Color of menstrual flow: Dark Red

NoneHeavy

Bright Red Bloody Mucous

Cramping (Mark all that apply)Mild During period Do you feel ovulation?Moderate After period Bleeding between periods Severe Cramping in low back Infertility issuesBefore period In groin area Do you use pain medication?

What kind?

Clotting (mark all that apply) Size of clotts: Bright color Brown / Grainy DimeStringy Dark in color Nickel

LargerVaginal Discharge

White discharge Red & white dischargeYellow discharge yellow discharge with pussGreenish Watery/thick discharge

fishy smell/leathery smellDo you experience:

Vaginal dryness Use lubricants during intercourse?

Mark all that apply:Pelvic inflammatory disease Ovarian CystsSTD's Hot FlashesEndometriosis Breast CystsMastitis Yeast infection/Vaginitis/Other discharge

Impotence Weak erectionDischarge from penis Prostate problemsTesticular pain or lump infertilityPremature ejaculation Low sex driveSTD's Do you wake with morning erection?

WOMEN ONLY

Menstruation and Menstrual Cycle

MEN ONLY


Fresh Red Purple/Blackish color

If yes, products used:

Please Describe your appetite:

Strong Normal Poor

Do you hunger quickly? Yes No

Please describe your diet (Examples: avoids bad fats, low-carb, high protein, vegetarian etc.)

Please list what you ate yesterday

Breakfast:

Lunch:

Dinner:

Snacks:

How much water do you drink per day?

List other types of fluids you drink:

Please describe your thirst

Strong Normal Poor

If you eat any of the following, please check and list how often/how much per week:

Candy

Cookies/Baked Goods

Chocolate

White Flour Bread

Soda - Regular / Diet

Milk

Cheese

Alcohol

Fast Food

Protein

Dark Green Vegetables

Fruit

Other

Are there any foods that you eat that make you feel bad/gas/bloating/HA/indigestion?

If yes, please list.

Please list food allergies that you have been diagnosed with:

SUPPLIMENTS:

NOTES / ANYTHING ELSE WE SHOULD KNOW

NAME PURPOSE HOW LONG

DIET INFORMATION


wellness questionair › wp-content › uploads › 2019 › 06 › ... · tpa wellness * 43422...

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