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Emergency Contact
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Medical Info
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General Health
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Claims / Benefit
Conditions
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Shoulder/Neck Tension
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Insomnia 11pm-3am
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Blurred Vision
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Emotional Eater
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Irritability/Anger
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Feeling of Lump in Throat
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Ringing in Ears
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Depression/Stress
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Teeth Clenching at Night
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Eczema
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Tension
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Herpes Simplex
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Red/Dry/Itchy Eyes
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Joints/Neck/Shoulder Pain
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Indecisive
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Fullness Below Ribs
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Gall Stones
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Intermittent Mild Fever
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Poor Circulation
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Energy Level
Clear
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High
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Even
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Agitated
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Flat
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Chaotic
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Low
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Fatigue
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Dull
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Vibrant
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KID/UB (Water)
Dark Under Eyes
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Urinary Problems
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Poor Memory
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Weak Leg/Knees
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Bladder Problems
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Loss of Hair
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Rapid Weight Change
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Lack of Bladder Control
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Hearing Problems
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Emotional Instability
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Weakness/Pain in Lower Back
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Cavities/Tooth Loss
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Thyroid Problems
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Decrease Bone Density
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Craving/Avoiding Salty Foods
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Tendency to Gain Weight
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Feel Cold Easily
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Fear
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Brain Foggy
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Low Sex Drive
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Hot Flash/Night Sweating
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Excess Worry
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Excessive Sexual Drive
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HT/SI (Fire)
Lymph Swelling
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Dry Scalp
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Hot Palms/Soles
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Heart Palpitations
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Skin Rash
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Bitter Taste in Mouth
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Chest Pain
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Aversion to Heat
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Thirst
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Gum Problems
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Insomnia/Sleep Problems
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Excess Joy
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Facial Redness
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Easily Startled
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Cysts/Tumor
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Nose Bleed
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Restlessness/Agitation
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Ear Infection
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Itchy/Burning Skin
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Vivid Dreams
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Sore Throat
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Night Sweats
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Lack of Joy in Life
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TMJ (Jaw)
Ear Blockage
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Clicking
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Difficulty Opening Jaw
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Locking
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Difficulty Chewing
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Clenching
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Morning Stiffness
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Ear Ringing
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Ear Stuffiness
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Ear Pressure
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Jaw Pain
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Acupuncture
Carpal Tunnel
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Numbness
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Cold Hands/Feet
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Bursitis/Tendonitis
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Fatigue
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Arthritis
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Sciatica
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Nerve Pain
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LU/LI (Metal)
Skin Rashes/Hives
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Bronchitis
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Snoring
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Dry Cough
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Grief/Sadness
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Cough with Sputum
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Shortness of Breath
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Nasal Discharge
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Asthma/Allergies
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Post-Nasal Drip
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Low Resistance to Colds/Flu
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Sinus Trouble
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Sneezing
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Dry Mouth/Throat/Nose
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Energy
Do you struggle with insomnia?
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Does your energy fluctuate?
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Is your energy constant?
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When is your energy lowest?
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What is your energy level upon awakening?
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How long do you sleep on average?
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SP/ST (Earth)
Heaviness Anywhere in Body
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Crave Sweets
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Diarrhea
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Fatigue/Worse After Eating
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Hypoglycemia
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Abdominal Pain
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Hard to Get Up In AM
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Difficulty Digesting Fats/Oils
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Indigestion/Heartburn
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Over-Thinking
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Edema (Swelling)
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Nausea/Vomiting
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Muscles Feel Tired Often
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Gas/Belching
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Easily Bruising & Bleeding
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Insulin Sensitivity
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Bad Breath
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Hemorrhoids
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Decreased/Increased Appetite
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Constipation
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Female Health
First Period
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Last Period
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Number of Pregnancies
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Number of Live Births
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Last PAP test
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Abnormal PAP test
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Irregular Periods
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Menstrual Cycle Length
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Menstrual Period Length
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Menstrual Cramping
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Heavy Bleeding
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Endometriosis
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Infertility
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Unwanted hair growth
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Premenstrual Syndrome
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Breast Cancer
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Ovarian Cancer
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Osteoporosis
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Current Menopausal Concerns
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Currently Pregnant
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Birth Control Method
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Implants
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Treatment: Surgery
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Date of Surgery
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Lymph Nodes Removed
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Side Effects of Surgery
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Reconstruction Date
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Treatment: Chemotherapy
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Number of Chemo Treatments
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Side Effects of Chemo
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Treatment: Radiation
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Number of Radiation Treatments
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Area of Radiation
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Nodes Irradiated
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Side Effects of Radiation
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Other Treatments
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Medical Devices
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Nausea
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Vomiting
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Mouth Sores
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Weight Loss
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Weight Gain
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Bone Pain
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Adhesions
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Incision
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Pressure Sensitivity
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Pain
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Former Injuries
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Loss of Movement
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Abnormal Skin Sensation
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Memory Problems
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Edema
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Low Platelet
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Low White Count
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Blood Clot
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Excessively Warm/Cold
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Lymphedema
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Heart Condition
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Lung Condition
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Dry Skin
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Fragile Skin
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Radiation Skin Reaction
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Hair Loss
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Fatigue
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Systemic Infection
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Infectious Condition
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Current Tumour
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Enlarged Lymph Nodes
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Enlarged Spleen
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Enlarged Liver
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Radioactivity
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Area of Complaint
Left Side of Neck
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Right Side of Neck
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Left Side of Upper Back
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Right Side of Upper Back
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Left Side of Mid Back
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Right Side of Mid Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Right Leg
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Left Hip
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Right Hip
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Brain Disorders
Social Anxiety Disorder
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ADD
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Depression
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ADHD
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Generalized Anxiety Disorder
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Autism
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Obsessive Compulsive Disorder
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Asperger Syndrome
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Obsessive Compulsive Personality Disorder
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Acute Stress Disorder
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Bipolar Disorder
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Panic Disorder
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Agoraphobia
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Borderline Personality Disorder
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PTSD
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Anorexia Nervosa
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Bulimia Nervosa
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Schizophrenia
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Sleep Disorder
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Antisocial Personality Disorder
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Claustrophobia
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Headaches
Migraines
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Cluster
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Headaches
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Rebound
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Sinus
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Chronic Daily Headache
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Tension
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Other Headaches
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Cardiovascular
Heart Attack
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Cardiovascular Conditions
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Varicose Veins
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Congenital Heart Defect
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Phlebitis
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Blood Pressure
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Blood Clots
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Acute Coronary Syndrome
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Coronary Artery Disease
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Lymphedema
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Aneurysm
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Hyperlipidemia
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Pericarditis
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Cardiovascular Accident
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Angina
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Cold Hands
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Raynaud Disease
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Pacemaker
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Atherosclerosis
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Cold Feet
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Rheumatic Heart Disease
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Heart Disease
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Cardiac Arrhythmia
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High Blood Pressure
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Valve Disorders
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Chronic Ischemic Heart Disease
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Low Blood Pressure
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Myocardial infarction
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Chronic Venous Insufficiency
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Congestive Heart Failure
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Musculoskeletal
Strain/Sprain
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Hereditary/Congenital Deformity
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Amyotrophic Lateral Sclerosis (ALS)
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Joint Injury
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Muscular Dystrophy
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Osteoporosis
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Osgood-Schlatter Disease
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Osteoarthritis
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Myasthenia Gravis
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Gout
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Ankylosing Spondylitis
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Osteomalacia
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Tendonitis/Bursitis
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Bone Disease
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Sinus Problems
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Paget Disease
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Artificial Joints / Special Equipment
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Compartment Syndrome
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Psoriatic Arthritis
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Dislocation
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Fibromyalgia
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Scleroderma
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Scoliosis
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Arthritis
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Jaw Pain (TMJD)
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Fracture
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Gastrointestinal
Poor Appetite
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Digestive Conditions
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Constipation
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Stomach Disorder
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Diarrhea
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Crohn's Disease
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Ulcerative Colitis
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Diverticulitis
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Eating Disorder
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Esophageal Disorder
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Fecal Impaction
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Celiac Disease
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Intestinal Polyps
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Irritable Bowel Syndrome
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Neurological
Tingling
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Brain Injury
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Multiple Sclerosis
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Stabbing
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Cerebral Vascular Accident (Stroke)
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