Type your answers to the questions in the form boxes below and check the box next to the items which apply to you.  We make every effort to return your evaluated questionnaire within 48 hours. All Information given on this form will be confidential.   It is used only for purposes of diagnosis.

 Name               Age       Gender MALE FEMALE

 Address         Zip code      

 E-mail                     Tel

Medical Background
What is the main thing you would like help with?
(Describe in your own words what you experience)

If you have been given a Western Medicine diagnosis what is it?

When did the condition begin?

What were the related circumstances?

To what extent does this condition interfere with your daily activities (work, sleep, exercise, sex, etc.)

Please list any chronic illnesses or conditions you have had or have now.

 Please list major childhood illnesses you have had.

Please list any surgeries you have had.

 Please list any significant trauma you have had.

Do  you have or have you had any of the conditions listed below?

Arthritis	Heart attack	Hyperthyroid	Rheumatic fever
Asthma	Heart disease	Hypothyroid	Scarlet fever
Cancer	Haemophilia	Kidney disease	Seizures or epilepsy
Coronary artery disease	Hepatitis	Kidney infection	STD
Diabetes	Herpes I or II	Kidney stones	Stroke
Eczema	High blood pressure	Liver disease	Tuberculosis
Gallstones	HIV or Aids	Mononucleosis

Please list all drugs and herbs that you take.

Perspiration Do you:

Perspire when you should	Perspire on slight exertion	Perspire for no apparent reason
Perspire profusely	Not perspire	Have night sweats
Have cold sweats	Have foul perspiration odour

Temperature
What is your subjective sense of your body temperature? 

Do you:

Tend to be hot/warm	Tend to be cold/cool	Have a low grade fever all of the time
Have a low grade fever in the afternoon or evening	Feel warmer  in the afternoon or evening	Have heat or warmth in your palms or soles
Have heat or warmth in your lower back	Have deep heat in your body	Have recurrent fevers
Have recurrent chills	Have cold hands	Have cold feet
Have cold in your lower back	Have chilly arms	Have chilly legs
Prefer hot/warm drinks	At specific times
Prefer cold/cool drinks	At specific times

Sleep
Do you:
Have difficulty going to sleep?Awaken during the night?   What time?
Have difficulty returning to sleep?      Sleep shallowly?      Have dreams disturb your sleep?    
Have difficulty awakening in the morning?     Feel tired or sleepy during the day?    
Need to take naps?     Feel "wired and tired"?      Get a "second wind" at night?

Exercise
What kind and how much exercise do you get weekly?

Are your symptoms and signs: better with exercise?  worse with exercise?
How is your general energy level?  Sufficient     Too Much    Too Little
How is your energy level after eating? Same   Increased    Decreased

How does your energy level vary during the day?

Do you:
Have shortness of breath?
Have shortness of breath on slight exertion?
Have loose stools?                         

Digestion and Diet

What percentage of your diet is cooked?

What percentage (rough estimate) of your diet is:

• Vegetables
• Fruits  
• True whole grains (not dough products)
• Meats, nuts, dairy

Do you:

Have regular meals? Times?	Feel like your abdomen is bloated or distended?	Have sour regurgitation or belching?
Taste your food?	Have a "noisy" stomach?	Have indigestion?
Have stomach pain or cramping?	Have abdominal pain or cramping?	Have problematic bad breath?
Tend toward constipation?	Tend toward loose stools?

Appetite:
poor good excessive constant

Do you crave these tastes
salty, sour, bitter,sweet, spicy?

Avoid these tastes
salty, sour, bitter,sweet, spicy?

Have gas?
flatulence or  belching?

Have 
nausea or   vomiting?

Stools
What color are your stools?  Does it vary?

How many bowel movements do you have in a day?

What time(s) do they occur?

Do You:

Have hard stools?	Have soft stools?	Have diarrhoea often?
Notice undigested food in your stools?	Notice blood in  your stools?	Notice blood on  your stools?
Notice a foul or repugnant odour from your stools?	Notice a mucus-like substance in or on your stools	Notice "coffee grounds" in your stools?

Urine

What color is your urine (without vitamins)?

How often do you urinate in a day?

Is your liquid intake about equal to your output?

Do You:

Awaken at night to urinate?  How many times?

Have an urgent feeling when you have to urinate?	Have difficulty starting urination?	Have an intermittent flow (starting and stopping)?
Have a weak flow?	Have pain when you urinate?	Notice "mistiness" in your urine?
Notice "cloudiness" in your urine?	Notice a "milky" quality to urine?	Notice "sand" or "grit" in your urine?
Notice blood in your urine?	Have strong-smelling urine?	Have urinary tract infections?

Reproduction
How often do you engage in sexual activity?

Do you:
Have low sexual energy?
Have excessive sexual energy?
Have pain during sex?
Have premature ejaculation?
Have seminal emission?
Have a discharge from your genitals?

Color?                                         Odour?                                       Consistency?
     

Have pain in your genitals?
Have itching in/on your genitals?
Experience impotence?
Are you pregnant now or have reason to believe you are?
How many pregnancies have you had?
How many children have you borne? 
Have you had any miscarriages?   How many ?
Have you had any abortions?  How many?
How long is your menstrual cycle? days
Is it regular?   How long is your menstrual flow?
What color is your menstrual flow?
Do you use birth control pills? If so, name of pill? How long?

Do you have cramps during your menstrual flow?	Are the cramps somewhat painful?	Are the cramps very painful?
Are there clots in your menstrual flow?	Are there few clots?	Are there many clots?
Do you have other pain with your menstrual flow?

Respiration - Do you have:

Shortness of breath?	Shortness of breath which is worse when lying down?	Difficulty inhaling?
Difficulty exhaling?	Sneezing?

A cough?  
dry      wet     hacking      productive     unproductive    blood
clear sputum     colored sputum    copious sputum     small amounts of sputum   
difficulty expectorating

Constricted nasal passages?       Sinus: congestionpaininfections   

Pain - Do you have:

Rapid onset?	Dull pain?	Gradual onset?
Sharp pain?	Burning pain?	Low back pain?
Fixed location?	Joint pain?	Shifting location?
Pain under the ribs?	Chest pain?

Headaches?   Where?  

Eyes - Do you:

Have a change in vision?	Have blurry vision?	Have red eyes?
Have dry eyes?	Have gritty eyes?	Have poor night vision?
See floaters?	Have itchy eyes?	Have watery eyes?

Ears - Do you:

Have difficulty hearing?        
      Have a ringing in your ears?    High-pitched    Low-pitched
Have ear pain?
Feel pressure in your ears?
Have discharges from your ears?

Nose
Is your nose obstructed?
Do you have nosebleeds?
Is your nose dry?

Mouth - Do you have:

Tongue ulcers	Bleeding gums	Sour regurgitation?
Bitter taste in your mouth?	Other tastes in your mouth?

Teeth
What is the condition of your teeth.   
Do you have tooth pain?

Throat

Sore throats?	Difficulty swallowing?
Sensation of something being your throat?	Phlegm in your throat?

Muscles - Do you have:

Muscle weakness?  Where  

Muscle tension?       Where  

Muscle aches?         Where  

Muscle cramps?      Where  

Muscle tics?              Where 

Muscle spasms?     Where  

Miscellaneous

Are  any of these categories of emotion predominant?

Fear     Anger      Joy       Shock       Worry       Sadness 

Have you recently had any exceptionally stressful  experiences. 
 

Do you:       

Have poor memory?	Have mental restlessness?	Feel your heart beat?
Have dizziness?	Have brittle nails?	Have rashes?
Have thirst without a desire to drink?	Have itching?	Have difficulty concentrating?

Have a feeling of heaviness?     Body      Head       Limbs   

Have swelling due to retention of fluids?  Where?  

 Please list additional information or concerns you wish to address.