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Chinese diagnosis is based upon the indications that reflect the condition of the internal organs. The more indications you can give, the more precisely we can form a picture of the disharmony present in you. So Please do not hesitate to typewrite your complaints in detail on separate paper and send it to us along with the Online Questionnaire below. Your evaluation will be returned to you as soon as possible with recommendations.
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Online Questionnaire
Name: _________________________________________ [ ]M [ ]F
Date of Birth: ___________________________
Address: _______________________________ Apt# ______ City ________________
State ____________ Country ______________________ Zip Cord _________________
E-mail Address: ______________________ Fax: _______________________
Chief Complaint:_______________________________________________________________
______________________________________________________________________________
Other Complaints: ______________________________________________________________
______________________________________________________________________________
When did you first notice this condition? _____________________________________________
What makes it better? ____________________________________________________________
What makes it worse? ____________________________________________________________
Did you go to see a doctor about this condition? If yes, what is his/her diagnosis?
________________________________________________________________________________
Medications/Herbs you are currently taking if any: _____________________________________
Serious illness you have had: ________________________________________________________
Serious injuries you have had: _______________________________________________________
Operations you have had: __________________________________________________________
Allergies: ________________________________________________________________________
Please circle all your indications that apply to you.
GENERAL:
Easily tired Low energy
Feeling sleepy after eating Sensation of heaviness
Anxiety Irritability Angry easily
Sighing
Depression Frighten
easily Edema/where _______________
Forgetfulness Dry
skin Itchy skin Bruise
easily Hair loss/Thinning
Boils Hives
Aversion to Cold Aversion to Hot Cold limbs Cold back Hot sensation in palms & soles
Spontaneous sweats Night sweats Afternoon fever
Trouble falling asleep Trouble staying asleep Excessive dreaming
HEAD:
Headache ( Frontal
Temporal Occipital Vertical )
Heavy sensation in head Dizziness
EYES:
Eye pain Red eyes
Dry eyes Blurred vision
Darkness under eyes Swelling
under eyes
EARS:
Poor hearing
Earaches Ear discharge
Ringing in ears ( Loud, high-pitch noise Low-pitch noise like rushing water )
NOSE:
Nasal discharge ( Clear
Yellowish ) Nasal Congestion
Frequent nose bleeds
MOUTH:
Thirst Dry mouth
Taste in mouth ( Bitter
Sweet Sour Salty
Pungent Lack of taste )
Grinding teeth at
night Difficulty swallowing
CHEST:
Shortness of breath
Palpitations Harder to inhale than exhale
Hypochondriac pain
Cough Phlegm ( White
Yellow )
STOMACH:
Poor appetite Excessive
appetite Frequent belching
Flatulence Nausea Vomiting Heartburn
STOOLS:
Hard Loose
Small/bitty Foul smell Diarrhea
Constipation
Alternation of constipation and diarrhea
URINE:
Clear Yellow
Cloudy Difficult
Frequent Frequent at night Burning/painful
Dripping Scanty Large amount
Female Only:
Pregnant PMS Hot
flashes Cycle(
Early Late Irregular No )
Bleeding ( Heavy Scanty ) Blood color ( Dark- red Bright-red Pale Purple or blackish )
Discharges ( White Yellow Thick Watery Fishy smell Leathery smell )
Pains ( Before the periods During the periods After the periods ) Clots
On
contraceptive pills
___________________________________________________________________________
Aloha Holistic Clinic 5 Remington Irvnie, CA 92620
E-Mail rainbow@alohaholistic.com
Copyright(C) 1999 by Aloha Holistic Clinic. All Rights Reserved.