VIKTOR NEDELCHEV, R.Ac
434 East Columbia Street, New Westminster,BC
Fuscaldo Chiropractic Total Health Centre
Office: 604-515-7018 Fax: 604-515-7058
Cell: 778-865-2123 www.qiinmotion.com
PATIENT INFORMATION FORM
Last name: ______________________________First name: _______________________________
Address: ________________________________City/Postal Code: _______________________________
Email Address: ___________________________Cell Phone: ____________________________________
Home Phone: ____________________________Work Phone: ___________________________________
Date of Birth: ____________________________Age: _________________________________________
Marital Status: ___________________________Children: ______________________________________
Occupation: _____________________________Family Physician: ________________________________
Emergency Contact: _______________________Phone
: _________________________________
Who may we thank for referring
you to this clinic: ______________________________________
The following questions will help us in determining your treatment
plan:
Have you received Traditional Chinese Medicine
treatments in the past? Yes No
If so, what type of treatments have you received? Acupuncture Herbology Tui Na
Have
you been diagnosed with any type of illness by your family doctor
or other specialist of Western
medicine? If yes please
specify: ___________________________________________________________
Do
you have heart disease? Yes No Do
you have a pacemaker? Yes No
Do
you have any allergies? If yes, please specify______________________________________________
Do
you take some medication? If yes please specify____________________________________________
Reason
for Today Visit:__________________________________________________________________
Patient Clinical Form
Chief Complaint:_____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Chief complaint
history: How, when and where did
this condition start? ______________________________________________________________________________________________
______________________________________________________________________________________________
__________________________________________________________________________________________
What types of treatments
have you tried, if any? _____________________________________________
____________________________________________________________________________________
What makes it better? __________________________________________________________________
What makes it worse? __________________________________________________________________
Please list any other health
problems you would like to address in order of importance: _______________
____________________________________________________________________________________
Medical History:
Diseases, Allergies, Surgeries, Accidents/ include years/
____________________________________________________________________________________
_____________________________________________________________________________________
Family Medical History (Mother, Father, Siblings): __________________________________________
Current medications, supplements and vitamins: ___________________________________________
_____________________________________________________________________________________
Do you currently have or have you ever had any of the
following? Please circle:
Anemia Epilepsy Fibromyalgia Arthritis Diabetes Multiple
Sclerosis
Schizophrenia Drug
Problem Digestive Disorders Bulimia High
cholesterol
Anorexia Tuberculosis Cancer Hepatitis HIV Snoring Seizures
High Blood Pressure Kidney
Disease Osteoporosis Asthma Stroke
Ulcers Thyroid
disease Kidney Stones Gall
Stones Alcoholism AIDS
Bipolar disorders Depression Mania Mood
swings Irritability
Frozen shoulder Carpal
tunnel syndrome Bleeding
disorder
Lifestyle and Nutrition:
Do you follow a special diet? Yes No If
yes, how would you describe the diet?
__________________________________________________________________________________
What do you eat on a typical
day?
Breakfast___________________________________________________________________________
Lunch______________________________________________________________________________
Dinner____________________________________________________________________________
Snacks______________________________________________________________________________
Do you crave any particular
foods?________________________________________________________
Exercise Yes No How
often ________________Type _____________________________
Sleep: Hours per night________Rested
in the morning? Yes No
Trouble falling asleep? Yes No Trouble
staying asleep? Yes No
Work:Enjoy work? Yes No Hours
per week working _______________________________
Hobbies: ____________________________________________________________________________
Please check all that apply:
Yes No Quantity Yes No Quantity
Coffee :_____________________________________Water :__________________________________
Tobacco :___________________________________Recreational Drugs :_________________________
Alcohol :____________________________________Soda pop :________________________________
Cigarettes :__________________________________Tea
:
General Symptoms (please check all that apply):
0
- never 1 - rarely 2
- occasionally 3 - frequently 4
- always
0 1 2 3 4 poor
appetite 0 1 2 3 4 constant
hunger
0 1 2 3 4 loose
stools 0 1 2 3 4 heartburn/acid
reflux
0 1 2 3 4 gas/abdominal
bloating 0 1 2 3 4 mouth
sores
0 1 2 3 4 fatigue
after eating 0 1 2 3 4 belching
or vomiting
0 1 2 3 4 hemorrhoids 0 1 2 3 4 gums
bleeding
0 1 2 3 4 bruise
easily 0 1 2 3 4 thirst
0 1 2 3 4 anemia 0 1 2 3 4 bad
breath
___________________________________________________________________________________
0 1 2 3 4 abnormal
sweating 0 1 2 3 4 fatigue
0 1 2 3 4 allergies 0 1 2 3 4 catch
colds easily
0 1 2 3 4 asthma 0 1 2 3 4 tired
after little exertion
0 1 2 3 4 shortness
of breath 0 1 2 3 4 general
weakness
0 1 2 3 4 cough 0 1 2 3 4 nasal
discharge
0 1 2 3 4 dry
nose/mouth/skin/throat 0 1 2 3 4 sinus
infection
________________________________________________________________________
0 1 2 3 4 sore,
cold or weak knees 0 1 2 3 4 feel
cold often
0 1 2 3 4 low
back pain 0 1 2 3 4 swollen
ankles
0 1 2 3 4 muscle
spasm, twitching, cramps 0 1 2 3 4 joint
pain
0 1 2 3 4 frequent
urination 0 1 2 3 4 poor
memory
0 1 2 3 4 urinary
incontinence 0 1 2 3 4 hair
loss
0 1 2 3 4 ear/hearing
problems 0 1 2 3 4 infertility
0 1 2 3 4 early
morning diarrhea
____________________________________________________________________________________
0 1 2 3 4 irritable 0 1 2 3 4 muscle
spasms/twitches
0 1 2 3 4 ligament/tendon
issues 0 1 2 3 4 numb
extremities
0 1 2 3 4 tight
feeling in chest 0 1 2 3 4 dry
irritated eyes
0 1 2 3 4 alternating
diarrhea/constipation 0 1 2 3 4 ear
ringing
0 1 2 3 4 sigh
frequently 0 1 2 3 4 easy
to be anger
0 1 2 3 4 neck/shoulder
stiffness 0 1 2 3 4 red
eyes
____________________________________________________________________________________
0 1 2 3 4 feel
heart beating 0 1 2 3 4 chest
pain
0 1 2 3 4 insomnia 0 1 2 3 4 disturbing
dreams
0 1 2 3 4 sores
on tip of tongue 0 1 2 3 4 restlessness
0 1 2 3 4 anxiety 0 1 2 3 4 palpitations
____________________________________________________________________________________
0 1 2 3 4 dizzy
upon standing 0 1 2 3 4 feeling
of heaviness
0 1 2 3 4 see
floaters in eyes 0 1 2 3 4 nausea
0 1 2 3 4 heat
in palms or soles 0 1 2 3 4 foggy
thinking
0 1 2 3 4 afternoon
fever 0 1 2 3 4 enlarged
lymph glands
0 1 2 3 4 night
sweats 0 1 2 3 4 cloudy
urine
0 1 2 3 4 frequently
flushed face
Urination:
Burning Urgent Scanty Difficult Profuse Dribbling Clear
Deep yellow Hematuria Nocturia Frequency/Volume______________________________
Bowel Movements:
Frequency per day ____________
Constipation Loose
stools Diarrhea Undigested
food Early morning diarrhea
Consistency (circle): Well-formed Hard Loose Alternates
between formed and loose
Do you ever notice any undigested
food, blood or mucous? ___________________________________
Are you Thirsty? Yes No If
so, do you prefer warm or cold drinks? _________________
Upon waking, do you have
a Bitter taste in your mouth? ______________________________________
Do you find that you like
particularly Hot or Cold? ____________________________________________
How is your Energy in general?
________________________________________________________
Do you often get Headaches
or Migraines? Yes No
How do you feel emotionally
right now? _____________________________________________________
Sweating:
Spontaneous Night
sweating Profuse cold Odor:_________________________________
Sex
drive: Low High Medium
Pain
:
Headache Chest Upper
abdominal Lower abdominal Lumbago
General
body ache Acute Chronic Persistent Lingering
Relieved
by by Heat / Cold / Pressure / Massage Aggravated
by Heat / Cold / Pressure / Massage
Are
you experiencing pain or discomfort in any area of your body? Yes No
If
yes, please indicate the location of the pain by using the symbols
that best describes your feeling:
XXX-sharp
stabbing pain OOO- pins/needles NNN
- numbness PPP- dull pain
Use
the following illustration to indicate painful or distressed areas:
For Women Only:
Are you currently pregnant? Yes No Are
you on the birth control pill? Yes No
Indicate the number of occurrences:
Pregnancies_____,Live births_____,Miscarriages_____,Abortions_____,D&C________________________
How old were you when you
had your first period?_____________________________________________
Have you experienced menopause?
(if applicable)
Yes No When?
_________________________
If you are experiencing menopausal
symptoms, please describe:__________________________________
______________________________________________________________________________________
Do you have a vaginal discharge? Yes No Please
describe the color and smell__________________
Is your period regular? Yes No When
was the first day of your last period?___________________
Average number of days of
flow:______,Flow is: Light Normal Heavy
Color is: Pale Normal Dark Bright
Red Brown Purple
Blood clots: Yes No
Do you get pain or cramps? Yes No Severe: Yes No
Nature of pain (circle):
Sharp Dull Constant Intermittent Burning Aching
Do you experience any of
the following before or during your menstrual period?
Edema Breast
tenderness/swelling Depression Irritability Migraines
Insomnia Diarrhea Constipation Nausea Hot
flashes Night sweating
Headache Fatigue Difficulty
with orgasm PMS Pain
with intercourse Vaginal discharge
Do you have a history of
the following:
Amenorrhea Breast implants Yeast infection Endometriosis Hysterectomy Infertility
Ovarian cyst
When did you have your last
Pap smear?________________ Last Mammogram_____________________
Any history of abnormal tests: Yes No
For Men Only:
Do you have any bothersome
urinary symptoms? Yes No
Date of your last prostate
Check up:___________,Results:____________________________________
General health symptoms:
Groin pain Decreased
libido Pain or swelling of testicles Impotence Increased
libido
Painful urination Difficult urination Frequent need to urinate at night Dribbling urination
Incontinence Premature
ejaculation Nocturnal emissions Difficulty
with orgasm
For the Practitioner
use only:
1.Pain 2.Food/taste 3.Stools/urine 4.Thirst/drink 5.Energy level 6.Head/face/body
7.Chest/abdomen 8.Limbs 9.Sleep 10.Sweating 11.Ears/eyes 12.Feeling of cold/heat/fever
13.Emotional symptoms 14.Sexual symptoms 15.Women´s symptoms 16.Children´s symptoms
Tongue diagnosis:
Spirit: Yes No
Body Shape:
Thin Swollen Stiff Flaccid Long Short Cracked Loose Deviated
Moving Numb Toot-marked Ulcerated Sore-covered Sublingual
vein congestion
Notes:_______________________________________________________________________________
Color:
Pale Normal Red Dark
red Purple Blue Purple
spots
Notes:________________________________________________________________________________
_____________________________________________________________________________________
Coating(Fur):
White Yellow Gray Black
Thin Thick Greasy Dry Slippery No
coating Moist Normal Peeled Miror
Notes:________________________________________________________________________________
Pulse per minute rate:_________
Left
side: Right side:
Cun Heart Lung
Guan Liver/Gall
Bladder Spleen/Stomach
Chi Kidney Kidney
Floating Sinking Deep Rapid Slow Thin Big Empty Full Slippery Thready
Wiry Choppy Tight Knotted Short Long Moderate Flooding Hidden
Hollow Scattered Intermittent Irregular Regularly
irregular
Notes_______________________________________________________________________________
____________________________________________________________________________________
TCM Diagnosis: _________________________________________________________
______________________________________________________________________
Treatment Plan: ________________________________________________________
______________________________________________________________________
Acupuncture Treatment: _________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Other Treatments: ______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Practitioner Signature:
Date: