Appointment Form New Form Step 1 of 6 16% FOR CONSULTATION APPOINTMENT1.Please complete the enclosed medical history forms, and bring them with you to your first appointment. 2. We require a minimum 24 hour notice of cancellation if you are unable to keep your appointment. The initial consultation is a service we provide free of charge to find out if we are able to help you with your current health problems, without cost of obligation. We set aside 2 hours for this appointment and would normally cost $140. There is no treatment at this appointment. To schedule your exam and treatment to follow, please call our office. FOR EXAM & FIRST TREATMENT APPOINTMENT 1. You should eat food within 6 hours of receiving your treatment. If you have not, a light snack is recommended. It is important that you do not eat a heavy meal or drink alcohol right before your treatment. 2. Depending on the nature of the complaint, needles may be retained for various lengths of time, and additional modalities may need to be used, thus resulting in varying treatment times. 3. It is not always necessary to disrobe. Depending on where the needles are placed, specific article of clothing may need to be removed. It is advisable to wear undergarments since it is not always possible to cover the body completely. 4. For accurate diagnosis, it is important to examine your tongue. If possible, do not brush your tongue the day or your exam and treatment. Additionally, try to avoid coffee, tea, or hard candies within 2 hours of treatment as these will falsely discolor the tongue. 5. Only pre-sterilized, disposable acupuncture needles are used. Needles are not reused. Please check the following that currently pertain to you (if you have symptoms in the following categories, it indicates that you have a problem with that organ's function): OVERALL ENERGY (Lung, Kidney function) Shortness of breath Difficulty keeping eyes open in the daytime Feel worse after exercise General weakness Low energy Easily catch colds OVERALL BLOOD (Liver, Spleen, Heart function) Dizziness See floating black spots HEART FUNCTION Palpitations Sores on the tip of the tongue Mental confusion Frequent dreams Anxiety Li' Restlessness Chest pain traveling to shoulder Wake unrefreshed Drink coffee (# of cups per week: LUNG FUNCTION Nasal Discharge (Color: Coughs Dry throat Sneezing Allergies (To what? Nose Bleeds Dry nose Achy feeling Headache (Location: ) Sinus Congestion Dry skin Stiff neck Smoke cigarettes (# of cigarettes a day: ) Dry Mouth Sore throat Stiff shoulders Alternating fever and chills Sadness Difficulty breathing Melancholy Please check the following that currently pertain to you (if you have symptoms in the following cat-egories, it indicates that you have a problem with that organ's function):SPLEEN FUNCTION Low appetite Abdominal gas Easily bruised Worry Abrupt weight gain Gurgling noise in the stomach Hemorrhoids Over-thinking Abrupt weight loss Fatigue after eating Pensive Abdominal bloating Prolapsed organs (previously diagnosed, which organ? SPLEEN, STOMACH, LARGE INTESTINE, SMALL INTESTINE FUNCTION Loose Incomplete Blood in stools Undigested food in stools Constipated Diarrhea Mucous in stools DAMPNESS TRAPPED IN THE BODY Loose Mental heaviness Swollen hands Chest congestion Mental sluggishness Swollen feet Nausea Mental fogginess Swollen joints Snoring General sensation of heaviness in the body Please check the following that currently pertain to you (if you have symptoms in the following cat-egories, it indicates that you have a problem with that organ's function):STOMACH FUNCTION Large appetite Heartburn Belching Bad breath Acid regurgitation Hiccups Mouth (canker) sores Ulcer (diagnosed) Stomach pain Burning sensation after eating Bleeding, swollen or painful gums Vomiting LIVER GALL BLADDER FUNCTION Alternating diarrhea and constipation Frustration Tingling sensation Convulsions Headache at the top of the head Depression Numbness Lump in the throat Tight sensation in the chest Irritability Muscle spasms Neck tension Bitter taste in the mouth Skin rashes Muscle twitching Drink alcohol High-pitched ringing in the ears Chest pain Muscle cramping Shoulder tension Gall stones (history or current) Anger easily Seizures Vertigo Limited Range-of-Motion Pain Under The ribcage Tendon. ligament or joint problems Limited Range-of-Motion, shoulder Sexually transmitted disease (Which? Recreational drugs (Which? , How much per week? Frequently unable to adapt to stress (What causes the stress? Please check the following that currently pertain to you (if you have symptoms in the following cat-egories, it indicates that you have a problem with that organ's function):EYES (Liver function) Itchy Dry Blurry vision Far-sighted Bloodshot Watery Decreased night vision Hot Gritty Near-sighted KIDNEY, URINARY BLADDER FUNCTION Frequent cavities Low back pain Bladder infections Easily broken bones Memory problems Wake during the night twice to urinate Sore knees Excessive hair loss Lack of bladder control Weak Knee Low-pitched ringing the ears Fear Cold sensation in the knees Kidney stones Easily startled URINATION Normal color Reddish Profuse Painful Urgent Dark yellow Cloudy Strong color Discharge Frequent Clear Scanty Burning Difficult LIBIDO Normal High Low WOMEN ONLY Yes No Number of childrenAge of first menstruation First Average number of days off low Vaginal discharge? Yes No Pregnant? Yes No Number of pregnancies:Age of menopause (if applicable): First Age of menopause (if applicable): Bleeding between periods? Yes No Do you experience any of the following pre-menstrual syndromes? URINATION Nausea Vomiting Water retention Breast swelling Food cravings Headaches Migraines Breast tenderness Depression Irritability Anxiety Other emotions Dull pain, Where? Sharp pain, Where?