COMPREHENSIVE QUESTIONNAIRE
Email *
Name *
TODAY'S DATE *
MM
/
DD
/
YYYY
Phone number *
DATE OF BIRTH *
MM
/
DD
/
YYYY
ADDRESS *
Height and Weight
DESCRIBE THE MAIN REASON FOR SEAKING ACUPUNCTURE TREATMENTS OR HERBAL MEDICINE *
DESCRIBE ALL ACTIVE MEDICAL PROBLEMS REGARDLESS OF IF YOU ARE SEAKING TREATMENT FOR THOSE PROBLEMS *
DESCRIBE ALL MAJOR ACCIDENTS, SURGERIES OR INJURIES *
DESCRIBE ALL TRAUMATIC EVENTS SUCH AS LOSS OR GRIEF, DIVORCE, ABUSE ETC *
LIST ALL ALLERGIES *
LIST ALL MEDICATIONS AND SUPPLEMENTS *
LIST ALL RECREATIONAL DRUG USE
DESCRIBE A TYPICAL DAILY DIET FOR YOU *
PAIN LEVEL TODAY *
WORST PAIN THIS WEEK *
LEAST PAIN THIS WEEK *
WHAT MAKES YOU FEEL BETTER? (heat, cold, rest etc) *
WHAT MAKES YOU FEEL WORSE?  *
CHECK ALL THAT APPLY LV/GB
CHECK ALL THAT APPLY HT/SI
CHECK ALL THAT APPLY SP/ST
CHECK ALL THAT APPLY LU/LI
CHECK ALL THAT APPLY KI/BL
PMS
YES
ABDOMINAL CRAMPS
IRRITABILITY
MOODINESS
EXCESS BLEEDING
SCANTY BLEEDING
BRIGHT RED BLOOD
DARK BLOOD
CLEARISH BLOOD
CLOTS
LONG PERIOD
SHORT PERIOD
NORMAL PERIOD
Clear selection
Hot / Cold
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