CHINESE MEDICINE ASSESSMENT FORM CLIENT INTAKE FORM * Required itemNameEmailDate of BirthAgeSexSelectMaleFemaleHeight (ft./inch)Weight (lbs)Marital StatusSelectSingleMarriedDivorcedOtherProfessionReferral SourceBlood PressurePulseTemperatureCholesterolTriglyceridesMedicationsPast OperationsIn your own words describe your chief complaint(s). PATIENT CONDITION INFORMATIONPlease click on all conditions that are relevant to you in Parts A-H, etc. and fill in text areas to clarify the condition, as needed. Part A: Please check any symptoms that apply to you now or in the last 3 months.Part A: Please check any symptoms that apply to you now or in the last 3 months. cough wheezing hoarseness loss of smell nasal discharge allergies itching eyes acne itchy skin vocal problems painful lymph nodes dry brittle hair fatigues after perspiring grief crave spicy foods dislike wind phlegm short of breath sneezing nasal congestion asthma hay fever sinus headaches perspire easily swollen glands sore throats dry skin smoker catch colds easily melancholy- sadness dislike dry weather dislike damp weather Part B: Please check any symptoms that apply to you now or in the last 3 months.Part B: Please check any symptoms that apply to you now or in the last 3 months. drooping eyelid prolapsed stomach nose bleeds loose stool stomach pain intestinal rumbling butterfly sensation in stomach poor short term memory inability to concentrate crave sweets cookies - cakes slow wound healing abdominal bloating discomfort after eating vomiting flatulence hernia prolapsed uterus gums bleed easily diarrhea heartburn ulcers gas alternating constipation & diarrhea constipation diarrhea bad breath poor long term memory loss of taste chocolate especially bruise easily poor digestion fatigue after eating nausea belching - burping hemorrhoidsBowel movements per dayKnown food allergiesAppetiteSelectHighLowModerate Part C: Part C: tight or constricted chest pains increase with stress high blood pressure vertigo yellow eyes/skin hiccups lower rib pain depression sensation of something in throat eyes tired blurred vision high cholesterol history of hepatitis anger easily clear throat often acid regurgitation eyes red spots before eyes irritable bitter taste in mouth frustration dizziness eyes sensitive eyes sore headache migraine high triglyceridesHeadache (where in the head) Part D. (Women Only)Color of flowSelectDarkLightClearMiscarriagesLength of flow# of pregnancyGyn surgeriesAge at first periodDate of last periodAge of menopauseRegular breast exam or mammogramPart D. Women Only painful menses irregular cycle cramps later in flow history of vaginal warts irregular pap test breasts painful breast distension fibrocystic breast/ovary infertility cycle (ie. every 28 days) clots recent change in cycle vaginal pain fibroid tumors cramps early in flowAdditional Premenstrual symptoms (describe)Additional Menopause symptoms (describe)Part E: (Men & Women) fatigue dark circles rheumatoid arthritis impotence intolerant of cold joints stiff fear morning diarrhea puffy beneath eyes loss teeth infertility abnormal thirst history of kidney stones pains get worse with exercise asthma memory loss awakens fatigued cold hands cold feet hearing loss weak/sore knees hair loss history if Kidney infection difficulty breathing anxiety excess energy swelling ankles lower back pain osteoarthritis spermatorrhea craves salt joints painful phobias seminal emission exposed to chemicals are under excessive stress work at a computerUninary Conditions painful urination burning/painful urination decreased stream or amount incontinence difficult urination urgent urination night urination chronic urinary infectionsUrination daily- Select -4-6 times6-10 times10+ timesUrine colorSelectDarkLightClearEar ringingSelectHighLowSlump time of daySex driveSelectHighLowNormalExercise Times/WeekPart F: speech problems jittery hot palms pale skin feeling of impending doom chest pain irritability flushing in afternoon sore tongue heart murmur scanty, yellow urine delirium sweat at night insomnia missed pulse beats dry mouth restlessness short of breath numb hands mouth sores chest congested Palpitations (feeling of heart beating, racing, or skipping beats)Please describe Part G: sense of heaviness muscle cramps brittle nails sedentary work twitches/spasms fever/chills weakness physical labor regular exerciseWhat drink temperature do you like?- Select -favor warm drinksfavors room tem drinksfavors cold drinksFavorite Color?Favorite Season of the year?Part H: (medication) Antacids Antibiotic/Antifungal Anti-inflammatory Chemotherapy High Blood Pressure Rx Laxatives Radiation Thyroid Ulcer Medications Antidepressants Glucose Regulator/Insulin Aspirin/Tylenol/Advil Heart Medications Hormones Oral Contraceptives Recreational Drugs Relaxants/Sleeping PillsOther Meds or details of above itemsPart I: Alternative Medicine Part I: Alternative Medicine vitamins peptides Chinese medicine minerals herb formulas energy medicine homeopathy Chiropractor Naturopathy herbs massage DieticianAdditional Alt Medicine servicesPart J:Check any you have had appendicitis typhoid fever Rheumatic fever malaria mumps small pox diabetes heart disease polio hearing loss herpes hepatitis obesity cancer goiter pleurisy chemical poisoning allergic reaction alcoholism eating disorders scarlet fever HIV nephritis anemia measles eczema diptheria pneumonia jaundice tuberculosis tonsillectomy epilepsy asthma heart attack influenza meningitis drug reaction whooping cough mental disorders venereal infectionPart K:Do You Eat, Drink or Use Alcohol Coffee Decaf Candy Cigarettes Carbonated Beverages Diet Sodas Distilled Water Fried Foods Fast foods, regularly Refined sugars Red meat, regularly Margarine diet often salt foods w/o tastingRestaurant (All kinds, how many times/wk?)- Select -1-3 times/Week4-6 times/Week7-10 times/Week11+ times/Week Exercise Times/Week Family History of: (list who in your family) StrokeHeart DiseaseCancer (who & what kinds)DiabetesMental DisorderGallbladder Disease Thyroid DiseaseAlzheimer'sNeurologic DiseaseAnything else you would like us to be aware of?Emotional Status-Depression (click item indicating your how you feel usually)Select1 (Mild Depression)23 (Moderate Depression)45 (Severe Depression)Emotional Status-Anxiety (click on item indicating your how you feel usually)Select1 (Mild Anxiety)23 (Moderate Anxiety)45 (Severe Anxiety) CURRENT DIET Please provide what a typical day would like. Record all the foods you eat and drink. Be sure to include the approximate amount of each food. The herbalist will provide a food therapy report if this section is incomplete. Your diet is key to better health. BreakfastMorning SnackLunchDinnerEvening Snack CONSTITUTION ASSESSMENT SECTION Scoring: Give yourself: 0 point for no condition exists (0 events per month)1 point for mild symptoms (1-2 events per month)2 points for moderate symptoms (3-6 events per month)3 points for a severe condition (7 events+ per month)If a condition doesn’t apply then leave the item blank. Men and women: Fill out both Yin and Yang sections below. For unclear items, consult your Traditional Chinese Medicine practitioner. YIN CONSTITUTION 1. Give yourself two Yin points, if you are a woman01232. Do you predominantly have feminine characteristics? (Men incl.)01233. Do you appear timid?01234. Do you stay indoors?01235. Easily tired? (tired from walking around the block)01236. Are you predominantly sluggish in your behavior?01237. Easily fall asleep when traveling by plane, train, or bus?01238. Are you more comfortable in winter-cold compared to summer-heat?01239. Overweight? (If yes, score 1 point for every 10 lbs. over normal weight for your sex & build. If over 30 lbs, then click 3-Critical.012310. Is food more than or just as appealing as sex? (libido question)012311. Is your sex drive weaker than normal (1=1 interruption/mth., 2=2-4 episodes/mth. 3=no function) (Kidney & health)0123 YIN: COLD CONSTITUTION1. Is your thirst usually quenched?01232. Do you like hot drinks more than cold drinks?01233. Do you normally have a pale complexion?01234. Is your urine usually plentiful and clear?01235. Bowel movements are normally soft?01236. Do you often have cold hands or feet? (1=sometimes, 3=always)01237. During cold weather do you experience muscular or joint pain?01238. Is the skin surface of your stomach, cool or cold? 0123 YIN: DAMP CONSTITUTION1. Do you often feel tired?01232. Are you overweight? (1=10 lbs., 2=20 lbs., 3=30 lbs.+)01233. Is your complexion usually dull?01234. Are you often sad or depressed?01235. Do your palms sweat?01236. Is your tongue usually glossy or greasy?01237. Do your joints ache when its raining?01238. Does your tongue have indentations on the side? (Look in mirror)0123 YIN: DEFICIENT CONSTITUTION1. Do you drink fluids throughout the day?01232. Are you often tired but appear to have abundant energy?01233. Are you skinny or underweight?01234. Do you sweat a lot?01235. Do you sometimes suffer from heart palpitations?01236. Is your tongue white or light pink without coating?01237. Do you experience (insomnia, irritability, worry, excess thought) 0123 YANG CONSTITUTION *Men and women: Fill out both Yin and Yang sections.1. If you are a man, give yourself 2 Yang points.01232. Do you consider yourself masculine?01233. Are you generally self-confident?01234. Are you the outdoor type?01235. Can you work for long stints without tiring?01236. Do you consider yourself energetic?01237. Do you find it difficult to sleep when traveling by plane, train, or bus?01238. Are your hands often hot?01239. Do your feet sweat?012310. Do you prefer the heat of summer to the cold of winter?012311. Are you underweight? (Score 1 point for 10 lbs. below the normal weight for your sex and build, 2=20 lbs., 3=30+ lbs.)012312. Do you consider your sex drive to be higher than normal? (Give yourself: 1 point: responsive, 2 point: strong and 3 points: very strong.)0123 YANG: HOT CONSTITUTION1. Do you normally prefer cold drinks over warm or hot ones?01232. Is your complexion generally reddish?01233. Is your urine usually scanty and of a reddish or yellowish hue?01234. Are you often constipated? (Score: 1 for 1 time per wk., 2 for 2 times per wk., 3 for 3 times +)01235. Are your stools usually dry?01236. Is your tongue normally red with a yellowish coating or no coating? (Look in the mirror)01237. Do you suffer from frequent skin eruptions or sores?01238. Do you stay up past 12 midnight? (1=hr., 2=2 hrs., 3=3+ hrs.)0123 YANG: DRY CONSTITUTION1. Are you often thirsty?01232. Are your nose & throat usually dry?01233. When you catch cold, is your cough usually dry without mucus?01234. Do your eyes and nose often itch?01235. Is your tongue frequently parched and dry?01236. Is it difficult for you to gain weight?01237. Are you often constipated? (Score: 1 for 1 time per wk., 2 for 2 times per wk., 3 for 3 times +)01238. Is your skin usually dry?0123 YANG: EXCESSIVE CONSTITUTION1. Are you usually full of energy? (always moving or doing things)01232. Do you consider yourself to be normally high-spirited?01233. Is the tone of your voice high-pitched?01234. Is your complexion usually flushed?01235. Is your blood pressure higher than normal? (1=10 pts higher, 2=20 pts higher or 3=30pts+ higher)01236. Are you restless and impatient?01237. Do you suffer from constipation? (Score: 1 for 1 time per wk., 2 for 2 times per wk., 3 for 3 times +)01238. Do you have any acid regurgitation, reflux, GERD, or hiatal hernia?0123 Final QuestionsEmotion: What emotion(s) do you experience most in your life? Anxiety Grief Depression Sadness Anger Worry Rage Joy Fear Hyper Impeding doom StressDid you get COVID? Yes NoDid you receive he COVID vaccine?SelectYesNoAny BosstersSelect1234Any COVID problems? Yes NoPlease describeSleep: How many hours? (night/avg.)Did you receive the COVID vaccine? Any boosters?Additional CommentsSUBMIT HERE
