Ni's Acupuncture Center
Form for non-office visit Diagnosis
Fax: (321) 454-9974
($80 diagnosis fee)
(Please use a word processor)
Instructions:
You can cut/paste the top portion of this document into a word processor and type in the answers or you can open a blank word processor document 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. Alternately you can open one of the documents below.
After filling in all the information, please print the document and fax to us at the number above.
Cut here (Top)
Name:
Credit card ($80 diagnosis fee + herbs + shipping):
Address:
Appetite:
Sleep:
Urine:
Bowel:
AM Yang:
Four Limbs:
Thirst:
Sweat:
Pains:
Other Comments:
Cut here (Bottom)
Name:
Be sure to enter your full name as it appears on your chart.
Credit Card:
Enter your credit card number and expiration date here if we do not already have this information in your file.
Address:
Enter you current mailing address here if it has changed or you are a new patient.
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.
LRB 05/17/2004