If you have any questions or concerns, please fill out our Short Contact Form, or email us directly, at LarisaTurin@chicagoacupuncture.com

New Patients: Please fill out the following consultation form, and send it to us, prior to your first appointment so that we can better service your needs.

 

Date

*

   Required Field

Name *
 
Mobile Phone *
Work Phone
Home Phone
Age
Gender *
Occupation
Address *
City * State * Zipcode *
Your Email * Referral *

Below, please describe all of your complaints, then list how long you have had them and how you are treating them last. Be sure to mention any drugs, vitamin supplements, or other medicinal substances you are taking.

Complaints
  How Long?  
  Yrs.
  Mon.
Treatment
  Yrs.
  Mon.
  Yrs.
  Mon.
  Yrs.
  Mon.
  Yrs.
  Mon.
Brief Health History: (list major diseases, surgeries, etc.)

How many times per year do you get a cold or the flu?

Diet: (summarize how you eat; list any special diet such as high protein, raw food, etc.)
Family Medical History:

Emotions:    normal problem

 depression  sadness  panic attack  sensitive

 worries  overly excited  angry  anxiety

Describe:



Energy:    normal problem

 low  up and down exhausted

 hyperactive  nervous energy  abundant

Describe:


Sleep Pattern:
 normal  Insomnia  
Falling asleep:  sometimes difficult  always difficult
   sometimes very difficult  always very difficult
   sleepy in daytime  takes naps
Waking up: Times per night  wake up too early
   wake up at night and cannot go back to sleep again
Sleep Quality:
 Deep  Light  Bad
 Many Dreams  Bad Dreams  Grinding Teeth
 Talking In Sleep  Other  
Describe:


Menstrual Cycle:  Regular Irregular


Age of onset: Yrs. old

Date of last period:

How many days per cycle?

How many days did it last?

Color:     Where there clots?  Yes No

Menstrual Pain:  Yes No

When did you feel pain?  Before flow during flow after flow

Where did you feel pain?  Abdomen Back Breasts

Emotions around Period:  Normal Abnormal

When do you feel most emotional?  Before flow during flow after flow

What emotions do you feel?  depression irritability anger sadness crying

Describe:



Temperature:    normal abnormal

 feel cold easily cold hands cold feet alternating hot & cold feel hot easily hot flash sensitive to weather changes

Describe:



Sweating:    normal abnormal

 too easily too much difficult too little night sweats other

Describe:



Sensitivity and Allergy:    normal problem

Temperature:  Cold Hot Dampness Light Noise Airborn particles Food Drugs Other

Describe:



Bowel Movement:  Normal Abnormal

Time of Day:

 constipation diarrhea loose watery incomplete hard and dry strong smell with mucous with blood other

Describe:



Body Weight:



If overweight:

How many pounds would you like to lose?

How many years ago did you first start to gain weight?

Are you following a weight control program at this time?

Describe:



Drinking:  Normal Abnormal

 Thirsty Dry Mouth Drink a lot Dry Mouth but no desire to drink

 Not thirsty, but drink a lot of water anyway

Describe:



Urination:  Normal Abnormal

 frequent urgent burning painful cloudy dark color foul smell bloody difficult retention other

Describe:



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