Good Life Acupuncture
7209 Curry Ford Road
Suite A
Orlando, FL 32822
ph: 407-223-0806
chengmin
Instructions:
You can cut/paste the top portion of this document into a word processor and type in the answers and answer the questions with just the heading above each section. Notepad is a very simple word processor that comes with windows. The first section below is to cut out for a template. Below that is more detailed guidelines/questions to help you better inform us of your problems.
After filling in all the information, please email the document or fax to us at the number above.
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Name:
Address:
Phone:
Email:
Date of Birth: Sex: Weight:
*Refer by:
Chief Concern:
Appetite:
Sleep:
Urine:
Bowel:
AM Yang:
Four Limbs:
Thirst:
Sweat:
Pains:
Other Comments:
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Detailed Guidelines
Name:
Be sure to enter your full name as it appears on your chart.
Address:
Enter you current mailing address here if it has changed or you are a new patient.
Chief Concern:
The main reason you need this diagnosis
Appetite:
Do you feel hungry at: Breakfast? Lunch? Dinner?
How is your ability to taste food?
Do you consume small, moderate, or large amounts of food at mealtimes?
Do use sea salt in your cooking. Do not use refined sugars. Eat like a king for breakfast, a prince for lunch, and a pauper for dinner.
Sleep:
Are you able to sleep through the entire night without waking up?
Do you feel adequately rested upon rising?
Additional comment concerning your sleep pattern:
Urine:
Do you urinate approximately 5 to 7 times per day?
What is the color of your urine?
Is your urine clear or cloudy?
Do you take vitamins? If so stop taking them, they only feed the flies.
Do you have a small, moderate, or large amount of urine?
Is there adequate force when urinating?
Additional comments or concerns about your urine:
Bowel:
Do you have a bowel movement at least once a day in the morning?
Is the texture of your stools firm and long?
What is the color of your stools?
Do you have the feeling of having adequately emptied your bowels?
Additional comments or concerns about your bowel:
AM Yang:
(MALES) Do you have an erection upon waking first thing in the morning?
(FEMALES) Are your nipples erect upon waking first thing in the morning?
Four Limbs:
Does your forehead feel cool and comfortable compared to the temperature of your hands?
Does the back of your hands and tops of your feet feel cooler than the palms and soles?
Do you have to keep your feet covered at night?
Thirst:
Do you have any type of abnormal thirst? Note that it is normal to have some thirst after sweating from exertion. The amount of thirst that you have should be in proportion to your activity level and the environment.
Do you prefer warm, room temp, cool, or cold water?
Drinking hot teas is good for your body. The fluids in fruits do more to rehydrate your body than drinking anything.
Sweat:
Do you have any type of abnormal sweating? Like sweating for no reason or night sweats.
Can you sweat?
Pains:
Do you have any pains in your legs, arms, back, etc?
If so do you know what caused them (accident for instance)?
How long have you had these pains?
Does pressure or touch make your pains feel better or worse?
Other Comments:
List any other symptoms, concerns, and questions here.
Phone Diagnosis is not recommended for most patient. Come to our office for standard diagnosis (face by face) will be more beneficial for the patient. However, if can not visit our doctor in person by some reason, you may chose this option.
You should send a check with amount USD$70 for the diagnosis fee.
This article contain information from my teach Dr. Ni's website: www.hantang.com
Copyright 2009 Good Life Acupuncture. All rights reserved.
Good Life Acupuncture
7209 Curry Ford Road
Suite A
Orlando, FL 32822
ph: 407-223-0806
chengmin