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DIAGNOSIS FORM

 


 
  Describe in your own words  main thing you would like help with.

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 any surgeries you have had.

Please list any significant trauma you have had.

Please list all drugs and herbs that you take.

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

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

Perspiration -Do you:

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

 

Temperature - Do you:

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

Sleep - Do you:

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

Exercise & Energy

How much exercise do you get weekly
Are your symptoms and signs:
better with exercise worse with exercise the same
How is your general energy level
Sufficient Too Much Too Little
How is your energy level after eating
Same Increased Decreased

Appetite - Do you:

Have a poor good excessive constant appetite
Crave these tastes salty sour, bitter sweet spicy
Avoid these tastes salty sour, bitter sweet spicy

Digestion  - Do you:

Have regular meals Have abdominal pain or cramping
Taste your food Have problematic bad breath
Have a "noisy" stomach Have flatulence
Have indigestion Have belching
Feel like your abdomen is bloated Have nausea
Have sour regurgitation or belching Have vomiting
Have stomach pain or cramping  

Stools - Do You:

Tend toward constipation Notice blood in your stools
Tend toward loose stools Notice blood on your stools
Have hard stools Notice a foul or repugnant odor
    from your stools
Have soft stools Notice a mucus-like substance in
    or on your stools
Have diarrhea often Notice "coffee grounds" in your
    stools
Notice undigested food in your
    stools 		 
What color are your stools
Number of daily bowel movements

Urine - Do You:

Awaken at night to urinate Notice "cloudiness" in your urine
Have an urgent feeling when you have
    to urinate 		Notice a "milky" quality to urine
Have difficulty starting urination Notice "sand" or "grit" in your urine
Have an intermittent flow (starting
    and stopping) 		Notice blood in your urine
Have a weak flow Have strong-smelling urine
Have pain when you urinate Have urinary tract infections 
Notice "mistiness" in your urine  
What color is your urine (w/o vitamins)  
How often do you urinate in a day
Is your liquid intake about equal to your output

Reproduction - Men & Women - Do you: 

Have low sexual energy Experience impotence
Have excessive sexual energy Have itching in/on your genitals
Have pain during sex Have pain in your genitals
Have premature ejaculation Have an odor from your genitals?
Have seminal emission  
Have a discharge from your genitals? What color?
How often do you engage in sex

Reproduction - Women

Are you pregnant now or have reason to believe you are
cramps during your menstrual
    flow 		Are there clots in your menstrual flow
        few clots many clots
Are the cramps somewhat painful
Are the cramps very painful
How long is your menstrual cycle days
Is it regular     Yes No
How long is your menstrual flow
What color is your menstrual flow
Do You use birth control pills? How long?
How many pregnancies have you had
How many children have you borne
How many miscarriages
How many abortions

Respiration - Do you have:

Have shortness of breath clear phlegm
Have shortness of breath on slight
    exertion		 colored phlegm
Shortness of breath which is worse
    when lying down 		small amounts of phlegm
Difficulty inhaling large amounts of  phlegm
Difficulty exhaling difficulty coughing phlegm up
Sneezing Sinus congestion
A cough dry  wet Sinus infections

Pain - Do you have:

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

Headaches Frontal Side Back Behind the eyes

HEAD TO TOES

Eyes - Do you have:

Ears - Do you:
change in vision Have difficulty hearing
blurry vision Have noise in your ears
High-pitched Low-pitched
red eyes
dry eyes Have ear pain
gritty eyes Feel pressure in your ears
poor night vision Have discharges from your ears
See floaters  
 

Mouth - Do you have:
Tongue ulcers Bitter taste in your mouth
Bleeding gums Other tastes in your mouth
 

Teeth
What is the condition of your teeth.
no fillings or crowns few fillings or crowns many fillings or crowns
Do you have tooth pain

Throat - Do you have:

Nose - Do you have:
mild sore throats often obstructed nose
Difficulty swallowing nosebleeds
Sensation of something in your
    throat 		dry nose
Phlegm in your throat
 

Muscles - Do you have:
Muscle weakness Where

Muscle tension Where

Muscle aches

Muscle tics
Muscle cramps   Muscle spasms
 
Emotional/Mental/Thinking - Do you have:
Have poor memory Have difficulty concentrating
Have mental restlessness any stressful experiences.
Are any of these emotions predominant
 Fear Anger Joy Shock Worry Sadness
 

Miscellaneous - Do you:
Feel your heart beat Have thirst without a desire to drink
Have dizziness Have rashes
Have brittle nails Have itching
Have a feeling of heaviness Body Head Arms or Legs

Please list additional information or concerns you wish to address.

Complete Table of Contents


 

 

 

 

 

 

 

 

 

 

 

 

 

 

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