Patient information form
This form is designed to collect necessary information about your general health. Because Chinese Energy Therapy Treatment requires an understanding of your whole health condition, this will assist us in working out where your energy blockage is, and how your symptoms relate to your inner organs.
Then we will be able to design the individual treatment plan for you. Please try to answer the questions as correctly as possible, that would be appreciated. All the information will remain confidential and is protected by the Privacy Act 1993.
Name *
Your answer
Date of Birthday *
MM
/
DD
/
YYYY
Gender *
address
Your answer
Phone number
Your answer
Occupation
Your answer
email address *
Your answer
NHI (National Health Index) *
Your answer
Blood Pressure
Your answer
Pulse rate
Your answer
weight
Your answer
family medical history
Your answer
your medical history (including any surgery) *
Your answer
Do you have any metal implants in your body? *
Have you been living/working in environmentally Polluted areas? *
Details if you have been working/living in environmentally polluted areas.
Your answer
Allergies
Your answer
Diet? What foods do you like or dislike?
Your answer
what food give you indigestion?
Your answer
Who do you live with (family members, partner, flatmates, or alone etc)? *
Your answer
Who does the cooking in your household?
Based on your food intake for one day, what do you typically eat? *
Breakfast
Your answer
Lunch
Your answer
Dinner
Your answer
Do you drink coffee? *
How often do you drink coffee?
Your answer
Do you drink alcohol? *
How often do you drink alcohol?
Your answer
Do you smoke? *
How often do you smoke?
Your answer
What time do you go to bed? *
Time
:
how many times do you need to go to toilet at night *
Your answer
Sleep: Insomnia/staying asleep/lethargy awakening/dreams/amount *
Your answer
Do you have a good appetite? *
Do you have reflux? *
Do you feel bloated after meals? *
Do you feel sleepy after meals *
Do you suffer from burping or wind? *
Do you have an irregular heart beat? *
Sweating: time/location/quality *
Your answer
Urine: function/pain/color/amount/time/incontinence/frequency/smell *
Your answer
Have you got any problem with your bowels? *
How many times a day do you have bowel motion? *
Your answer
Stools: constipation/diarrhea/pain/burning/mucus/smell/flatulence/quantity/regular/time
Your answer
Do you suffer from water retention? *
Where is the water retention? feet/ankle/legs/hands/face/eyes
Your answer
Do you suffer from low Libido? *
Menstruation: Cycle/discharge-amount/color/quality/pain
Your answer
Do you have menopausal problem?
Any hot flushes? how often?
Your answer
Leucorrhoea: consistency/smell/color
Your answer
Pregnancy: infertility/morning sickness/miscarriage/children
Your answer
Do you have headaches? *
How often do you have headaches?
Your answer
Headache: location/quality/aggravated/relieved?
Your answer
What painkillers do you take?
Your answer
How often do you take painkillers
Your answer
Skin: condition/scars/acne/eczema?
Your answer
ears: Tinnitus/deafness/discharge
Your answer
eyes: pain/dryness/floaters/blurring/vision deteriorating?
Your answer
Do you perspire a lot? Day or night *
Your answer
Does your skin bruise easily? *
Musculoskeletal: Pain location/sharp/dull/relieved/aggravated/acute/chronic/sore areas of body?
Your answer
Do you have sore feet or ankles? *
Do you have numb feet? *
Do you have cold hands and feet? *
Do you have hot burning feet? *
Chills and Fever: aversion/preference/presence
Your answer
Are you short of breath? *
For how long are you short of breath?
Your answer
Do you have a dry cough? *
For how long do you have a dry cough?
Your answer
Throat: Pain/blockages?
Your answer
Do you have problems swallowing food? *
Mouth: Gums/ulcers
Your answer
Nose: Sinus/discharge
Your answer
Do you have any phlegm? *
What is the colour of your phlegm?
Your answer
Emotions: Reactions to stress
Your answer
Do you have anxiety attacks? *
How long do you have anxiety attacks?
Your answer
Are you unable to relax? *
How long are you unable to relax?
Your answer
Are you able to concentrate? *
How long are you able to concentrate?
Your answer
Do you have difficulty in making decisions? *
Do you find your memory is deteriorating? *
Describe your current health problems and how long have you had them?
Your answer
Aggravation: Heat/cold
Your answer
Has this problem been medically diagnosed?
What was the diagnosis?
Your answer
How was it confirmed? Blood test/ X-Rays/ Others
Your answer
what treatment have you received previously?
Your answer
What was the result?
Your answer
Are you on any medication? *
What medication are you taking now, and for what reasons?
Your answer
What exercise do you do?
Your answer
how often do you do exercise?
Your answer
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