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Acupuncture Center of Baltimore
Need Help? Call:
443 904-0364
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Energy
Does your energy fluctuate?
Is your energy constant?
When is your energy highest?
When is your energy lowest?
What is your energy level upon awakening?
How long do you sleep on average?
Do you struggle with insomnia?
Comments
Does your energy fluctuate?
Is your energy constant?
When is your energy highest?
When is your energy lowest?
What is your energy level upon awakening?
How long do you sleep on average?
Do you struggle with insomnia?
Emotion / Mood
Anxiety
Fear
Sadness
Depression
Grief
Despair
Negative Self-Talk
Anger
Other Emotions
PTSD
Stress Response and Coping Strategies
Overall mood and energy level
Rate the stress in your life (1-10)
Comments
Anxiety
Fear
Sadness
Depression
Grief
Despair
Negative Self-Talk
Anger
Other Emotions
PTSD
Stress Response and Coping Strategies
Overall mood and energy level
Rate the stress in your life (1-10)
Well Being
Exercise
Sports
Flexibility
Range of Motion
Hobbies
Interests
Comments
Exercise
Sports
Flexibility
Range of Motion
Hobbies
Interests
LIV/GB (Wood)
Irritability/Anger
Depression/Stress
Headaches/Migraines
Visual Problems
Red/Dry/Itchy Eyes
Gall Stones
Dizziness
Blurred Vision
Feeling of Lump in Throat
Teeth Clenching at Night
Muscle Cramping/Twitching
Tension
Joints/Neck/Shoulder Pain
Poor Circulation
Soft/Brittle Nails
Emotional Eater
Ringing in Ears
Eczema
Shingles
Herpes Simplex
Indecisive
Fullness Below Ribs
Shoulder/Neck Tension
Insomnia 11pm-3am
Intermittent Mild Fever
Comments
Irritability/Anger
Depression/Stress
Headaches/Migraines
Visual Problems
Red/Dry/Itchy Eyes
Gall Stones
Dizziness
Blurred Vision
Feeling of Lump in Throat
Teeth Clenching at Night
Muscle Cramping/Twitching
Tension
Joints/Neck/Shoulder Pain
Poor Circulation
Soft/Brittle Nails
Emotional Eater
Ringing in Ears
Eczema
Shingles
Herpes Simplex
Indecisive
Fullness Below Ribs
Shoulder/Neck Tension
Insomnia 11pm-3am
Intermittent Mild Fever
LU/LI (Metal)
Dry Cough
Cough with Sputum
Nasal Discharge
Post-Nasal Drip
Sinus Trouble
Dry Mouth/Throat/Nose
Skin Rashes/Hives
Snoring
Grief/Sadness
Shortness of Breath
Asthma/Allergies
Low Resistance to Colds/Flu
Sneezing
Bronchitis
Comments
Dry Cough
Cough with Sputum
Nasal Discharge
Post-Nasal Drip
Sinus Trouble
Dry Mouth/Throat/Nose
Skin Rashes/Hives
Snoring
Grief/Sadness
Shortness of Breath
Asthma/Allergies
Low Resistance to Colds/Flu
Sneezing
Bronchitis
HT/SI (Fire)
Heart Palpitations
Chest Pain
Insomnia/Sleep Problems
Easily Startled
Restlessness/Agitation
Vivid Dreams
Lack of Joy in Life
Dry Scalp
Skin Rash
Aversion to Heat
Thirst
Excess Joy
Cysts/Tumor
Ear Infection
Sore Throat
Lymph Swelling
Hot Palms/Soles
Bitter Taste in Mouth
Gum Problems
Facial Redness
Nose Bleed
Itchy/Burning Skin
Night Sweats
Comments
Heart Palpitations
Chest Pain
Insomnia/Sleep Problems
Easily Startled
Restlessness/Agitation
Vivid Dreams
Lack of Joy in Life
Dry Scalp
Skin Rash
Aversion to Heat
Thirst
Excess Joy
Cysts/Tumor
Ear Infection
Sore Throat
Lymph Swelling
Hot Palms/Soles
Bitter Taste in Mouth
Gum Problems
Facial Redness
Nose Bleed
Itchy/Burning Skin
Night Sweats
KID/UB (Water)
Urinary Problems
Bladder Problems
Lack of Bladder Control
Weakness/Pain in Lower Back
Decrease Bone Density
Feel Cold Easily
Low Sex Drive
Excessive Sexual Drive
Poor Memory
Loss of Hair
Hearing Problems
Cavities/Tooth Loss
Craving/Avoiding Salty Foods
Fear
Hot Flash/Night Sweating
Dark Under Eyes
Weak Leg/Knees
Rapid Weight Change
Emotional Instability
Thyroid Problems
Tendency to Gain Weight
Brain Foggy
Excess Worry
Comments
Urinary Problems
Bladder Problems
Lack of Bladder Control
Weakness/Pain in Lower Back
Decrease Bone Density
Feel Cold Easily
Low Sex Drive
Excessive Sexual Drive
Poor Memory
Loss of Hair
Hearing Problems
Cavities/Tooth Loss
Craving/Avoiding Salty Foods
Fear
Hot Flash/Night Sweating
Dark Under Eyes
Weak Leg/Knees
Rapid Weight Change
Emotional Instability
Thyroid Problems
Tendency to Gain Weight
Brain Foggy
Excess Worry
SP/ST (Earth)
Heaviness Anywhere in Body
Fatigue/Worse After Eating
Hard to Get Up In AM
Edema (Swelling)
Muscles Feel Tired Often
Easily Bruising & Bleeding
Bad Breath
Decreased/Increased Appetite
Crave Sweets
Hypoglycemia
Difficulty Digesting Fats/Oils
Nausea/Vomiting
Gas/Belching
Insulin Sensitivity
Hemorrhoids
Constipation
Diarrhea
Abdominal Pain
Indigestion/Heartburn
Over-Thinking
Comments
Heaviness Anywhere in Body
Fatigue/Worse After Eating
Hard to Get Up In AM
Edema (Swelling)
Muscles Feel Tired Often
Easily Bruising & Bleeding
Bad Breath
Decreased/Increased Appetite
Crave Sweets
Hypoglycemia
Difficulty Digesting Fats/Oils
Nausea/Vomiting
Gas/Belching
Insulin Sensitivity
Hemorrhoids
Constipation
Diarrhea
Abdominal Pain
Indigestion/Heartburn
Over-Thinking
Brain Disorders
Acute Stress Disorder
Agoraphobia
Anorexia Nervosa
Antisocial Personality Disorder
ADD
ADHD
Autism
Asperger Syndrome
Bipolar Disorder
Borderline Personality Disorder
Bulimia Nervosa
Claustrophobia
Depression
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Obsessive Compulsive Personality Disorder
Panic Disorder
PTSD
Schizophrenia
Sleep Disorder
Social Anxiety Disorder
Comments
Acute Stress Disorder
Agoraphobia
Anorexia Nervosa
Antisocial Personality Disorder
ADD
ADHD
Autism
Asperger Syndrome
Bipolar Disorder
Borderline Personality Disorder
Bulimia Nervosa
Claustrophobia
Depression
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Obsessive Compulsive Personality Disorder
Panic Disorder
PTSD
Schizophrenia
Sleep Disorder
Social Anxiety Disorder
Eating Habits
Breakfast
Lunch
Dinner
Snacks
Comments
Breakfast
Lunch
Dinner
Snacks
Family History
Arthritis
Cardiovascular
Respiratory
Comments
Arthritis
Cardiovascular
Respiratory
Area of Complaint
Left Side of Neck
Left Side of Low Back
Left Side of Mid Back
Left Side of Upper Back
Left Shoulder
Left Arm
Left Hand
Left Hip
Left Knee
Left Ankle
Left Foot
Left Leg
Right Leg
Right Side of Upper Back
Right Foot
Right Ankle
Right Knee
Right Side of Neck
Right Side of Low Back
Right Side of Mid Back
Right Shoulder
Right Arm
Right Hand
Right Hip
Right Elbow
Left Elbow
Right Wrist
Left Wrist
Chest
Abdomen
Left Groin
Right Groin
Left Gluteal
Right Gluteal
Comments
Left Side of Neck
Left Side of Low Back
Left Side of Mid Back
Left Side of Upper Back
Left Shoulder
Left Arm
Left Hand
Left Hip
Left Knee
Left Ankle
Left Foot
Left Leg
Right Leg
Right Side of Upper Back
Right Foot
Right Ankle
Right Knee
Right Side of Neck
Right Side of Low Back
Right Side of Mid Back
Right Shoulder
Right Arm
Right Hand
Right Hip
Right Elbow
Left Elbow
Right Wrist
Left Wrist
Chest
Abdomen
Left Groin
Right Groin
Left Gluteal
Right Gluteal
Headaches
Migraines
Headaches
Cluster
Rebound
Sinus
Chronic Daily Headache
Tension
Other Headaches
Comments
Migraines
Headaches
Cluster
Rebound
Sinus
Chronic Daily Headache
Tension
Other Headaches
Cardiovascular
High Blood Pressure
Low Blood Pressure
Congestive Heart Failure
Heart Attack
Phlebitis
Cardiovascular Accident
Pacemaker
Heart Disease
Cardiovascular Conditions
Myocardial infarction
Varicose Veins
Blood Clots
Lymphedema
Cold Hands
Cold Feet
Acute Coronary Syndrome
Aneurysm
Angina
Atherosclerosis
Cardiac Arrhythmia
Chronic Ischemic Heart Disease
Chronic Venous Insufficiency
Congenital Heart Defect
Coronary Artery Disease
Hyperlipidemia
Pericarditis
Raynaud Disease
Rheumatic Heart Disease
Valve Disorders
Blood Pressure
Comments
High Blood Pressure
Low Blood Pressure
Congestive Heart Failure
Heart Attack
Phlebitis
Cardiovascular Accident
Pacemaker
Heart Disease
Cardiovascular Conditions
Myocardial infarction
Varicose Veins
Blood Clots
Lymphedema
Cold Hands
Cold Feet
Acute Coronary Syndrome
Aneurysm
Angina
Atherosclerosis
Cardiac Arrhythmia
Chronic Ischemic Heart Disease
Chronic Venous Insufficiency
Congenital Heart Defect
Coronary Artery Disease
Hyperlipidemia
Pericarditis
Raynaud Disease
Rheumatic Heart Disease
Valve Disorders
Blood Pressure
Endocrine
Diabetes
Acute Pancreatitis
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Prostate Condition
Comments
Diabetes
Acute Pancreatitis
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Prostate Condition
Gastrointestinal
Digestive Conditions
Crohn's Disease
Celiac Disease
Constipation
Diarrhea
Diverticulitis
Eating Disorder
Esophageal Disorder
Fecal Impaction
Intestinal Polyps
Irritable Bowel Syndrome
Poor Appetite
Stomach Disorder
Ulcerative Colitis
Comments
Digestive Conditions
Crohn's Disease
Celiac Disease
Constipation
Diarrhea
Diverticulitis
Eating Disorder
Esophageal Disorder
Fecal Impaction
Intestinal Polyps
Irritable Bowel Syndrome
Poor Appetite
Stomach Disorder
Ulcerative Colitis
Hearing
Ear Problems
Hearing Loss
Conductive Hearing Loss
Meniere Disease
Motion Sickness
Tinnitus
Vertigo
Comments
Ear Problems
Hearing Loss
Conductive Hearing Loss
Meniere Disease
Motion Sickness
Tinnitus
Vertigo
Immune
Allergies
Cancer
Lupus
Rheumatoid Arthritis
Anaphylaxis
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Non-Hodgkin Lymphoma
Comments
Allergies
Cancer
Lupus
Rheumatoid Arthritis
Anaphylaxis
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Non-Hodgkin Lymphoma
Kidney
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Electrolyte Imbalance
Kidney Stones
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Comments
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Electrolyte Imbalance
Kidney Stones
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Musculoskeletal
Arthritis
Osteoporosis
Artificial Joints / Special Equipment
Sinus Problems
Fibromyalgia
Gout
Jaw Pain (TMJD)
Osteoarthritis
Ankylosing Spondylitis
Bone Disease
Compartment Syndrome
Dislocation
Fracture
Hereditary/Congenital Deformity
Joint Injury
Osgood-Schlatter Disease
Osteomalacia
Paget Disease
Psoriatic Arthritis
Scleroderma
Scoliosis
Strain/Sprain
Amyotrophic Lateral Sclerosis (ALS)
Muscular Dystrophy
Myasthenia Gravis
Tendonitis/Bursitis
Carpal Tunnel Syndrome
Plantar Fasciitis
Chronic Fatigue Syndrome
Spondylolisthesis
Whiplash
Comments
Arthritis
Osteoporosis
Artificial Joints / Special Equipment
Sinus Problems
Fibromyalgia
Gout
Jaw Pain (TMJD)
Osteoarthritis
Ankylosing Spondylitis
Bone Disease
Compartment Syndrome
Dislocation
Fracture
Hereditary/Congenital Deformity
Joint Injury
Osgood-Schlatter Disease
Osteomalacia
Paget Disease
Psoriatic Arthritis
Scleroderma
Scoliosis
Strain/Sprain
Amyotrophic Lateral Sclerosis (ALS)
Muscular Dystrophy
Myasthenia Gravis
Tendonitis/Bursitis
Carpal Tunnel Syndrome
Plantar Fasciitis
Chronic Fatigue Syndrome
Spondylolisthesis
Whiplash
Neurological
Stroke
Loss of Sensation
Epilepsy
Cerebral-vascular Accident
Shingles
Dizziness
Cerebral Palsy
Parkinsons
Herniated Disc
Multiple Sclerosis
Numbness
Burning
Tingling
Stabbing
Vertebral and Spinal Cord Injury
Huntington Disease
Brain Disorder
Chronic Pain Disorder
Brain Injury
Cerebral Vascular Accident (Stroke)
Seizure Disorder
Transient Ischemic Attacks (TIA)
Sciatic Pain
Comments
Stroke
Loss of Sensation
Epilepsy
Cerebral-vascular Accident
Shingles
Dizziness
Cerebral Palsy
Parkinsons
Herniated Disc
Multiple Sclerosis
Numbness
Burning
Tingling
Stabbing
Vertebral and Spinal Cord Injury
Huntington Disease
Brain Disorder
Chronic Pain Disorder
Brain Injury
Cerebral Vascular Accident (Stroke)
Seizure Disorder
Transient Ischemic Attacks (TIA)
Sciatic Pain
Reproductive
Pregnancy
Gynaecological Conditions
Breast Disorder
Ectopic Pregnancy
Endometriosis
Menopause
Menstrual Cycle Disorder
Ovarian Cysts/Tumors
Pelvic Inflammatory Disease
Premenstrual Syndrome
Uterine Disorder
Comments
Pregnancy
Gynaecological Conditions
Breast Disorder
Ectopic Pregnancy
Endometriosis
Menopause
Menstrual Cycle Disorder
Ovarian Cysts/Tumors
Pelvic Inflammatory Disease
Premenstrual Syndrome
Uterine Disorder
Respiratory
Chronic Cough
Shortness of Breath
Asthma
Emphysema
Bronchitis
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
COPD
Cystic Fibrosis
Tuberculosis
Comments
Chronic Cough
Shortness of Breath
Asthma
Emphysema
Bronchitis
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
COPD
Cystic Fibrosis
Tuberculosis
Skin
Skin Conditions
Skin Irritations
Infectious Skin Conditions
Herpes
Hypersensitive Reaction
Athlete's Foot
Melanoma
Bruise Easily
Acne
Allergic Dermatosis
Athletes Foot
Chemical Burn
Hypersensitive Reactions
Melanoma/Carcinoma
Pigmentary Disorder
Plantar's Wart
Psoriasis
Rash
Rosacea
UV Burn
Comments
Skin Conditions
Skin Irritations
Infectious Skin Conditions
Herpes
Hypersensitive Reaction
Athlete's Foot
Melanoma
Bruise Easily
Acne
Allergic Dermatosis
Athletes Foot
Chemical Burn
Hypersensitive Reactions
Melanoma/Carcinoma
Pigmentary Disorder
Plantar's Wart
Psoriasis
Rash
Rosacea
UV Burn
Miscellaneous
Vision Problems
Vision Loss
Mental Health Issues
Surgical Pins or Wire
Other Diagnosed Diseases
Insomnia
Other Medical Conditions
ADHD
Comments
Vision Problems
Vision Loss
Mental Health Issues
Surgical Pins or Wire
Other Diagnosed Diseases
Insomnia
Other Medical Conditions
ADHD
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