Please print out this questionnaire, fill it out, then scan it back into your computer and email it back to me at : mailto:

Thanks, Rebecca 

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Note: Information provided on this form is confidential.

To facilitate the process of Traditional Chinese Medical pattern diagnosis and determining the best treatment(s) to assist in your healing process, it is important that the information you provide be as complete as possible.


PATIENT NAME: _________________________________________________________

Date: _______________                                              

Age:  _____      Date of Birth: ____________________         Gender (circle):  M  /  F                

Marital Status:  _____Single      _____Married       _____Divorced       _____Widowed

Occupation:  ____________________________________________________________


Medication Allergies: ___________________________________________________________________

Food or Environmental Allergies: _________________________________________________________     

Describe your allergic symptoms or signs:  __________________________________________________





(Describe your symptoms or health issue for which you are seeking treatment.)


How long have you had this condition? ______________.   The onset was:  Sudden ____   / Gradual ____

Symptoms are relieved or improved by_____________________________________________________. 

Symptoms are worsened by______________________________________________________________.

What medical diagnosis have you received for this condition?   __________________________________

What other treatments have you received for this condition? ___________________________________


Can you relate the onset of your symptoms to any major event, or any change in lifestyle? (For example, a change in: diet, exercise, occupation, sleep, stress level, relationship, personal loss, etc.)   

Describe: ____________________________________________________________________________


On the following drawings, shade in the areas where you feel should be addressed.





IF YOU HAVE PAIN, please check words that best describe your pain:

____Sharp    ____Stabbing    ____Dull    ____Throbbing   ____Diffuse     ____Focused    ____Aching      ____Sore   ____Burning     ____Itching   ____Shooting, nerve-like pain    ____Tingling or numbness

____Intermittent (comes and goes)         ____Continuous

____Location of pain moves from place to place, or is difficult to locate

____Radiating (starts in one area and spreads to another)

Please add other descriptive words if the above do not describe your pain:


Is your pain accompanied by weakness or loss of function?  Yes /  No

Accompanied by redness, swelling, or other change in appearance of affected part?  Yes / No

Please describe ________________________________________________________________________


Please mark on the scale of 1 to 10, the number that represents the Severity of your pain:

EXAMPLE        (Not painful at all) 1__________________________7___________10 (worst pain ever felt)


YOUR PAIN:      (Not painful at all) 1_____________________________________10 (worst pain ever felt)



Medication Name


For What Condition?

How long have you been taking this medication?


























List any Herbs or other Supplements you are taking:

Herb, Supplement or Vitamin


For What Condition?

How long have you been taking this?


























Please describe any CURRENT THERAPIES you are undergoing:





Have you ever had acupuncture in the past?  Yes /  No

If yes, did you have regular treatments for a period of time? Yes /  No          For how long ?___________. 

What was your response? ______________________________________________________________.

Have you ever taken Traditional Chinese Herbal Formulas? Yes /  No

Have you ever taken recreational, or non-medical drugs?  YES /  NO

Have you ever taken hormones, either ‘over the counter’ or prescription?  YES /  NO



Are you currently pregnant? Yes /  No

Are you presently trying to get pregnant? Yes /  No




Circle any childhood illnesses you have had:

Measles, mumps,  rubella,  whooping cough,  chickenpox,  rheumatic fever,  scarlet fever,  polio.


List any surgeries, or hospitalizations, and dates these occurred.  _______________________________

_____________________________________________________________________________________  Health Maintenance:   Yearly Physical ______ Visual Exams_____     Dental Exams______   

If over 50, have you had a Colonoscopy? ____       BP checked? _____   Recent Blood Tests?_____

Adult Illnesses or Diagnoses

Check  if YES

Age or date of illness / diagnosis

Please circle the appropriate choice:

Cardiovascular disease



On medication / Resolved /  Neither




On medication / Resolved /  Neither




On medication / Resolved /  Neither

Thyroid disease



On medication / Resolved /  Neither

Respiratory Illness




On medication / Resolved /  Neither




On medication / Resolved /  Neither

Colitis or IBS



On medication / Resolved /  Neither

Hepatitis / Liver Disease



On medication / Resolved /  Neither

Urinary tract infections



On medication / Resolved /  Neither

Kidney disease



On medication / Resolved /  Neither

Arthritis / Gout



On medication / Resolved /  Neither




On medication / Resolved /  Neither




On medication / Resolved /  Neither




On treatment / Resolved /  Neither

Autoimmune Disorder



On medication / Resolved /  Neither




On medication / Resolved /  Neither

Neurological Disorder



On medication / Resolved /  Neither

Headaches/ Migraines



On medication / Resolved /  Neither

Mental/ Emotional Addictions



On medication / Resolved /  Neither

Others not listed:







On medication / Resolved /  Neither




On medication / Resolved /  Neither


If you answered YES to any of the above, please give additional details: __________________________________________________________________________________________________________________________________________________________________________

YOUR FAMILY HISTORY – Please indicate whether any family members have had any of the illnesses listed in the Past Medical History section, or others.  List or describe in the space provided.



Paternal GF


Paternal GM




Maternal GF


Maternal GF



















Traditional Chinese Medical diagnosis attempts to determine underlying patterns in your constitution and health condition. In order to identify these patterns, we need to ask questions that may seem unrelated to your condition. However, your answers are very important for your acupuncturist to be able decide on the proper treatment.


Please circle any symptoms you have experienced recently, to a significant degree,   or frequently, over a longer time period:



Feel cold often                 Feel hot/ warm  often     Hot flashes        Heat intolerance          Cold extremities

Sweating at night             Excessive sweating          Frequently thirsty           

No thirst              Desire cold drinks             Desire warm drinks          Thirsty but can’t drink much              



Fatigue                 Tired in the morning           Tired in the afternoon               Tired after meals

Best energy in morning         Best energy at night       Excessive Energy        Lack of motivation

Insomnia:            Difficulty falling asleep         Frequent awakening                 Early am awakening

Irritable/ restless sleep                  Frequent, vivid dreams                  Nightmares       

Easily Angered      Impatient            Unable to relax             Depressed              Hyperactive        Anxious        Perfectionist         Obsessive thinking                    Sadness          Unresolved grief               Fears or phobias    




Dizziness             Difficult concentration                   Poor memory                    Mental “fog”    

Headaches  or   migraines      Describe:_______________________________________________

Blurry Vision       See spots/floaters           Painful/red eyes               Dry Eyes              Itchy or Watery eyes      

Sinus congestion              Sinus pain            Allergies               Runny nose                       Nose bleeds                              

Ear pain               Ringing in ears                  Clogged/popping in ears               Hearing loss

Dry mouth          Cold sores           Mouth Sores      Bleeding gums   Breath odor     

Dry throat         Sore throat:  Frequent/ Mild/ Severe       Hoarseness






Frequent colds       Chest congestion       Dry cough           Cough with phlegm         (Color: ___________)

Shortness of breath on exertion                Shortness of breath at rest        Asthma               

Chest pain           Chest tightness                 Palpitations                       Pain in sides or ribs



Reflux (GERD)                  Stomach pain                     Nausea                Vomiting              Belching                                            Colic

Gas        Bloating        Constipation             Diarrhea              Painful bowel movements                Hemorrhoids



Lack of appetite                Frequent hunger        Excessive appetite                 Hungry but can’t eat

Eating disorder                 Food intolerances ______________________________________

Crave foods that are:          Sweet              Salty      Sour       Bitter       Spicy        Meaty                                                           Carbohydrates   



Difficult                Frequent              Urgent                 Painful                 Scanty                  Profuse                                             

Incontinence or leaking                 Weak stream                    Strong odor

Urine Color:        Clear/ pale          Yellow                  Cloudy                  Dark            Pink or with blood

Other:  ________________________________________________________________________



Weakness                                         Muscle wasting                 Heavy limbs        Decreased mobility

Spinal problems                 Osteoporosis                    Fractures              Joint pain            Joint swelling

Weak or sore back                         Weak or sore knees                         Hot, inflamed joints


EXTREMITIES:    Numbness          Tingling                 Bluish or white extremities           Hot palms and soles            



Prostate Enlargement                   Prostate Cancer                 Testicular Pain                  Inguinal Hernia

Low Libido                          Decreased Sexual Function                         History of fertility problems                                             

History of STD                    Genital Rash or other inflammation         Other ___________________________



Age of onset of menses: __________.

How many:   Pregnancies______,  Births______,  Miscarriages or Therapeutic Abortions______.

Are you on birth control pills (BCP’s)?  YES / NO.    If YES, what type and dosage? ___________________.  For how long?_______________________.

Do you use another type of birth control? If so, what type?__________________________.

Are you post-menopausal? YES / NO. 

Hormonal Replacement (HRT)?  YES /NO.  What type? ______________.  For how long?  ____________.

Do you have an annual gynecology exam and Pap screening done regularly?  YES / NO 

Any history of vaginal infections, STD’s or other inflammatory condition?_____________.

Do you do Breast Self-Exams? Circle:   Never            Rarely              Monthly              Weekly

If you are age 40 or older, are you current with annual screening mammograms?  YES / NO

Ever had an abnormal result on a Mammogram? ________.         On a Pap test? ________.


If you currently have periods, please answer the following questions regarding your menstrual pattern. 

If you are postmenopausal, please answer the questions regarding your menstrual pattern in the past.


Average Cycle length (from 1st day of period to 1st day of next period):  ________days.

Average days of flow:________ days.  

I have or had (check all that apply):

Irregular periods              Medium flow     Light flow            Heavy flow         Painful periods                  Clots

Vaginal itching/burning                  Spotting between periods            Discomfort before period

Discomfort/pain during period               Fatigue or other symptoms after period ___________________

Vaginal discharge     (Color_______________________)

History of:    uterine fibroids           ovarian cysts                  endometriosis                   fertility problems




If there is anything else that you wish to let us know about, ask about, or to have addressed in your treatment, please include additional information or questions here: __________________________________________________________________________________________________________________________________________________________________________

Thank you!

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