Acupuncture Questionnaire Name: _____________________________ Date: ____________ Primary Care Physician: _________________________________ Physician’s Phone Number: ______________________________ 1. Start by listing in order of importance (1 being the most important) the reasons you wish to see the doctor. 1. 2. 3. 4. Instructions: Please circle or check the answers that apply to you at least 80% of the time. Be nonjudgmental and don't think about the answers too much. Leave blank any boxes that do not apply to you or that you are unsure of. There are no correct answers. Your honesty will result in a better treatment. 2. Please circle one answer for each of the following questions. Five phase questions Wood Fire Water Earth My favorite season Spring Summer Winter Harvest (late summer) Autumn My favorite Blue – Green (turquoise) Red Dark Blue or Black Yellow (earth tones) White My favorite flavor Sour, citrus, acidic Bitter, roasted Sweetness Spicy, flavorful My predominant emotional tendency I tend to get angry. I am excitable. I get scared. I tend to worry. I tend to feel sad My predominant psychological characteristic I tend to be anxious and irritable. I am joyful and creative. I am willful and ambitious. I often find myself in deep thought. I tend to get depressed. My reaction to stress I clench. My muscles get tight. I tend to cry. I tremble. My body shaky. My stomach feels upset. My chest feels tight. My fingernails can be characterized as Elongated Long and narrow Crescent moon Triangular Rectangular 3. On the anatomical figures below mark the area or areas where you have pain or other problems. Please be as accurate as possible about the locations.
Pain Assessment Location: Onset: Makes Better: Makes Worse: Associated Symptoms: Quality: constant intermittent sharp dull pressure burning Severity: 1 2 3 4 5 6 7 8 9 10 Pain Assessment Location: Onset: Makes Better: Makes Worse: Associated Symptoms: Quality: constant intermittent dull pressure burning Severity: 1 2 3 4 5 6 7 8 9 10 Pain Assessment Location: Better: Worse: Associated Symptoms: Quality: constant intermittent sharp dull pressure burning Severity: 1 2 3 4 5 6 7 8 9 10 Treatments I’ve Physical therapy Chiropractic Injections ____________ 4. Please check any statements that apply to you. JUE YIN / SHAO YANG Fire MH Master of the Heart (KM) I can be characterized as irritable, anxious, nervous and emotionally unstable at times. I tend to harbor grudges and have explosive anger. I tend to get tension headaches or stress-related headaches. I have insomnia. I prefer dark chocolate. I tend to find problems in any situation. I experience premature ejaculation. I tend to repeat certain activities to relieve anxiety. I tend to obsess about things, including sex. TH Triple Heater (KT) I can be characterized as clear thinking and decisive. I get agitated and this results in insomnia. I tend to grind my teeth and have tight jaws. I tend to have great self-confidence. I have muscular aches and cramps. I tend to be well muscled, well and need to stretch. I generally speak rapidly. I experience hot flashes. I have ringing in my ears. I tend to tap my fingers and fidget. Wood GB I can be characterized as indecisive, well and/or having dark circles under my eyes.