Acupuncture Questionnaire Name: _____________________________ Date: ____________ Primary Care Physician: _________________________________ Physician’s Phone Number: ______________________________ 1. Start by listing in order of importance (1 being the most important) the reasons you wish to see the doctor. 1. 2. 3. 4. Instructions: Please circle or check the answers that apply to you at least 80% of the time. Be nonjudgmental and don't think about the answers too much. Leave blank any boxes that do not apply to you or that you are unsure of. There are no correct answers. Your honesty will result in a better treatment. 2. Please circle one answer for each of the following questions. Five phase Wood Fire Water Earth questions Harvest My favorite season Spring Summer Winter Autumn (late summer) Blue Green Dark Blue or Yellow – My favorite Red White (turquoise) Black (earth tones) Sour, citrus, Bitter, Spicy, My favorite flavor Sweetness acidic roasted flavorful My predominant I tend to get I am I tend to I tend to feel I get scared. emotional tendency angry. excitable. worry. sad My predominant I tend to be I am willful I often find I am joyful I tend to get psychological anxious and and myself in and creative. depressed. characteristic irritable. ambitious. deep thought. I clench. My I tremble. My My reaction to My stomach My chest muscles get I tend to cry. body feels upset. feels tight. stress tight. shaky. My fingernails can Long and Crescent Elongated Triangular Rectangular be characterized as narrow moon 3. On the anatomical figures below mark the area or areas where you have pain or other problems. Please be as accurate as possible about the locations.
Acupuncture Questionnaire Name: _____________________________ Date: ____________ Primary Care Physician: _________________________________ Physician’s Phone Number: ______________________________ 1. Start by listing in order of importance (1 being the most important) the reasons you wish to see the doctor. 1. 2. 3. 4. Instructions: Please circle or check the answers that apply to you at least 80% of the time. Be nonjudgmental and don't think about the answers too much. Leave blank any boxes that do not apply to you or that you are unsure of. There are no correct answers. Your honesty will result in a better treatment. 2. Please circle one answer for each of the following questions. Five phase questions Wood Fire Water Earth My favorite season Spring Summer Winter Harvest (late summer) Autumn My favorite Blue – Green (turquoise) Red Dark Blue or Black Yellow (earth tones) White My favorite flavor Sour, citrus, acidic Bitter, roasted Sweetness Spicy, flavorful My predominant emotional tendency I tend to get angry. I am excitable. I get scared. I tend to worry. I tend to feel sad My predominant psychological characteristic I tend to be anxious and irritable. I am joyful and creative. I am willful and ambitious. I often find myself in deep thought. I tend to get depressed. My reaction to stress I clench. My muscles get tight. I tend to cry. I tremble. My body shaky. My stomach feels upset. My chest feels tight. My fingernails can be characterized as Elongated Long and narrow Crescent moon Triangular Rectangular 3. On the anatomical figures below mark the area or areas where you have pain or other problems. Please be as accurate as possible about the locations.
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