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 General information *

Please fill in all of the applicable fields. Thorough information helps us serve you better.

Name: *

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Age:*

Gender:*

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Occupation:

Body Height in Meters:

(e.g.1.72m)
 
 Health History

 

Brief Health History:

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

Diet:

Summarize how you eat; list any special diet such as high protein, raw food, etc.

Family Medical History:

 
 Complaints/Treatment *

 

Please describe the chief complaints you are seeking treatment for: *

How long have you had these problems: *

What kinds of treatments have you tried for them: *

Please list medications, nutrition supplements and other substances you are currently taking: *

 
 Energy

 

Energy:
 Normal
 Problem
 Low
 Up and down
 Exhausted
 Hyperactive
 Nervous energy
 Abundant

Describe:

 
 Emotions

 

Emotions:
 Normal
 Problem
 Depression
 Sadness
 Panic attack
 Sensitive
 Worries
 Overly excited
 Angry
 Anxiety

Describe:

 
 Sleep Pattern

 

Sleep Pattern:

Normal
Insomnia

Falling Asleep:

 Sometimes difficult
 Always difficult
 Sometimes very difficult
 Always very difficult
 Sleepy in daytime
 Take naps

Waking up:

 Wake too early
 Wake up at night and cannot go back to sleep

How many times per night do you wake up?:

Sleep Quality:

 Deep
 Light
 Bad
 Many dreams
 Bad dreams
 Grinding teeth
 Talking in sleep
 Other (specify below)

Describe:

 
 Menstrual Cycle

 

Age of onset (in years):

Menstrual Cycle Regularity:

 Regular
 Irregular

How many days per cycle?:

How many days did it last?:

Color:

 Pale red
 Dark red
 Bright red
 Purplish

Menstrual Pain:

 Before flow
 During flow
 After flow
 Abdomen
 Back
 Breast
 No Pain

Emotion around period:

 Normal
 Abnormal
 Depression
 Irritability
 Anger
 Sadness
 Crying
 Other
 Before flow
 During flow
 After flow

Describe:

 
 Temperature

 

Temperature:

 Normal
 Abnormal
 Feel cold easily
 Cold hands
 Cold feet
 Alternating hot & cold
 Feel hot easily
 Hot flash
 Sensitive to weather changes

Describe:

 
 Sweating

 

Sweating:

 Normal
 Abnormal
 Too easily
 Too much
 Difficult
 Too little
 Night sweats
 Other

Describe:

 
 Sensitivity and Allergy

 

Sensitivity and Allergy:

 No
 Yes
 Cold
 Hot
 Dampness
 Light
 Noise
 Food
 Drugs
 Other

Describe:

 
 Appetite and Digestion

 

Appetite and Digestion:

 Normal
 Abnormal
 Rapid hungering
 Poor appetite
 Nausea
 Anorexia
 Hungry, but no desire to eat
 Bloating
 Gas
 Other

Describe:

 
 Bowel Movement

 

Bowel Movement:

Normal
Abnormal

How many times a day / a week?:

(If abnormal) Bowel Movement Type:

 Constipation
 Diarrhea
 Loose
 Watery
 Incomplete
 Hard and dry
 Strong smell
 With mucous
 With blood
 Other

Describe (colour? with undigested food? float or sink in toilet water?):

 
 Body Weight

 

Weight:

Normal
Overweight
Underweight

If overweight

 

How many lbs. would you like to lose?:

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

Are you currently following a weight control program?:

 Yes
 No
 

Describe your body weight:

 
 Drinking

 

Drinking:

Normal
Abnormal

If drinking is abnormal, how so

 

If drinking is abnormal, how so:

 Thirsty
 Dry mouth
 Drink a lot
 Dry mouth but no desire to drink
 Not thirsty, but drink a lot of water anyway
 
 
 Urination

 

Urination:

Normal
Abnormal

If urination is abnormal, how so

 

If urination is abnormal, how so:

 Frequent
 Urgent
 Burning
 Painful
 Cloudy
 Dark color
 Foul smell
 Bloody
 Difficult
 Retention
 Other
 

Number of times per day:

Number of times per night:

Describe your urination:

 

Patient Informed Consent:

1. I hereby request and consent to be treated by acupuncture and/or Chinese Herbal Remedies administered by the Practitioner at Fu's Natural Healing Center, hereinafter referred to as "Practitioner”.

2. I understand that acupuncture is performed by the insertion of fine, sterile disposable acupuncture needles (with or without the addition of electric current) through the skin, or the application of heat to the skin, or both, at certain points on the body, in an attempt to improve the body function and/or relieve pain.

3. I acknowledge that, although rare, certain side effects may result from acupuncture and / or herbal remedy. These can include bruising, mild pain or discomfort, a feeling of weakness, fainting, nausea, and a temporary aggravation of symptoms. These effects are unusual and often of short duration.

4. I accept that no guarantee is made concerning the use and effects of acupuncture or Chinese herbal remedies.

5. I understand that I may stop treatment at any time.

6. I understand that the evaluation given me is an energetic assessment based on the acupuncture channel system. When statements are made regarding the state of various "organs", such as the heart, liver, kidneys, etc., they refer to the energetics of the acupuncture channels of the same name.

7. I acknowledge that Practitioner is not a western-trained medical doctor and does not advise on the use of medically prescribed pharmaceuticals or medical treatment, nor does he give any substances by injection.

8. I acknowledge that Practitioner is fully qualified, experienced, registered and insured in the United Kingdom.

9. I understand that the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.

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