Patient Name:  DOB:

Main reason for visit:


When did the problems begin:


What type of treatment(s) have you tried for your problem? AccupunctureCranial SacralVitaminsCranialOsteopathyDrugs Other Prior Treatments:
Which of the therapies have been most helpful:
List other areas of your health that you would like help with. When did they begin?

Autonomic & Acid Base

Sympathetic

Mild Moderate Severe Dry mouth, eyes, nose	Mild Moderate Severe Staring, blinks little	Mild Moderate Severe Feverish
Mild Moderate Severe Easily startled, unable to relax	Mild Moderate Severe Gets cold/cold seats	Mild Moderate Severe Can't fall asleep
Mild Moderate Severe Sweaty/clammy palms, soles, forehead, underarms	Mild Moderate Severe Strong light irritates	Mild Moderate Severe Nervous stomach
Mild Moderate Severe Heartburn

Parasympathetic

Mild Moderate Severe Slow starter	Mild Moderate Severe Eyes blinking often	Mild Moderate Severe Gag reflex, difficulty swallowing
Mild Moderate Severe Eyes, nose watery	Mild Moderate Severe Perspires easily	Mild Moderate Severe Constipation, Diarrhea alteration
Mild Moderate Severe Slow pulse "irregular"	Mild Moderate Severe Joints stiff after arising	Mild Moderate Severe Always seems hungry

Sugar Handling

Mild Moderate Severe Eat when nervous	Mild Moderate Severe Get "shaken" if hungry	Mild Moderate Severe Abnormal craving for snacks
Mild Moderate Severe Awaken afterhours of sleep	Mild Moderate Severe Eating relieves fatique	Mild Moderate Severe Overeating sweats upsets
Mild Moderate Severe Afternoon headaches	Mild Moderate Severe Moods of depression	Mild Moderate Severe Excessive appetite
Mild Moderate Severe Light headed if meals missed	Mild Moderate Severe Crave candy or coffee in the afternoon	Mild Moderate Severe Hungy or irritable between meals

Cardiovascular

Mild Moderate Severe Chest pains	Mild Moderate Severe Low/high bood pressure	Mild Moderate Severe Blue/black spots
Mild Moderate Severe Feet swelling at night	Mild Moderate Severe Irregular heartbeat	Mild Moderate Severe Low iron
Mild Moderate Severe Often drowsey	Mild Moderate Severe Numbness in the arms	Mild Moderate Severe Sigh freguently
Mild Moderate Severe Varicose veins	Mild Moderate Severe Stroke/mini stroke	Mild Moderate Severe Low B-12
Mild Moderate Severe Cold fevers	Mild Moderate Severe Bruise easily	Mild Moderate Severe Muscle cramps, Charlie Horse
Mild Moderate Severe Afternoon yawner	Mild Moderate Severe Nosebleeds	Mild Moderate Severe History of amnesia
Mild Moderate Severe Dizzy when standing up

Gastrointestinal & Digestion

Liver and Bilary

Mild Moderate Severe Gallstones	Mild Moderate Severe Itching skin	Mild Moderate Severe Hail falling out
Mild Moderate Severe Stools light colored	Mild Moderate Severe Burning/itching	Mild Moderate Severe Burning feet
Mild Moderate Severe Lactose intolerant	Mild Moderate Severe Queasy feeling	Mild Moderate Severe Fatty food intolerant
Mild Moderate Severe Dry skin	Mild Moderate Severe Bad breath	Mild Moderate Severe Insecure

Digestion

Mild Moderate Severe Black bloody stool	Mild Moderate Severe Foul smelling stool	Mild Moderate Severe Large amounts of gas
Mild Moderate Severe Indigestion after eating	Mild Moderate Severe Bloated after eating	Mild Moderate Severe Cramp low abdomen
Mild Moderate Severe Burping or beleching	Mild Moderate Severe Hepititis/Ulcers	Mild Moderate Severe Irritable bowels
Mild Moderate Severe Coated tongue	Mild Moderate Severe Heartburn/indigestion	Mild Moderate Severe Hausea/vomiting

Skin, Hair and Nails

Mild Moderate Severe Itching	Mild Moderate Severe Dandruff	Mild Moderate Severe Acne/pimples
Mild Moderate Severe Sunbearned easily	Mild Moderate Severe Hair falls out	Mild Moderate Severe Flushing or blotches
Mild Moderate Severe Hives	Mild Moderate Severe Premature grey hair	Mild Moderate Severe Rough skin on arm
Mild Moderate Severe Psoriasis	Mild Moderate Severe Hand nails	Mild Moderate Severe Poor would healing
Mild Moderate Severe Rashes	Mild Moderate Severe Eczema	Mild Moderate Severe Corners of mouth cracked
Mild Moderate Severe Brittle fingernails	Mild Moderate Severe Greasy skin	Mild Moderate Severe Recent moles

Endocrine Glands

Hyerthyroid

Mild Moderate Severe Increase of weight	Mild Moderate Severe Constipation	Mild Moderate Severe Fatigue easily
Mild Moderate Severe Intolerance to cold	Mild Moderate Severe Mental sluggishness	Mild Moderate Severe Appetite decreased
Mild Moderate Severe Slow pulse	Mild Moderate Severe Dry scaly skin	Mild Moderate Severe Coarse hair falls out

Hyper-pituitary

Mild Moderate Severe Low Blood pressure

Mild Moderate Severe Increased sex life

Mild Moderate Severe Failing memory

Hypo-pituitary

Mild Moderate Severe Always thirsty

Mild Moderate Severe Bloating of abdomen

Mild Moderate Severe Decreased sex life

Hyper-adrenal

Mild Moderate Severe Dizziness	Mild Moderate Severe Facial/body hair (females)	Mild Moderate Severe Hot flashes
Mild Moderate Severe Headaches

Hypo-adrenal

Mild Moderate Severe Weakness, dizziness	Mild Moderate Severe Low blood pressure	Mild Moderate Severe Crave salt
Mild Moderate Severe Arthiritis tendancies	Mild Moderate Severe Respitory disorder	Mild Moderate Severe Weakness after a cold or flu

Male & Female Specific

Female

Mild Moderate Severe Menstrual cramps	Mild Moderate Severe Missed mentruation	Mild Moderate Severe Painful breasts
Mild Moderate Severe Frequent yeast infections	Mild Moderate Severe Irregular periods	Mild Moderate Severe Premenstrual depression
Mild Moderate Severe Hot flashes	Mild Moderate Severe Excessive/prolonged menstruation	Mild Moderate Severe Anxiety before period
Mild Moderate Severe Ovaries removesd

Males

Mild Moderate Severe Prostate trouble	Mild Moderate Severe Diminished sex drive	Mild Moderate Severe Feeling impotent
Mild Moderate Severe Frequent urination at night	Mild Moderate Severe Tired easily	Mild Moderate Severe Migrating aches &pains
Mild Moderate Severe Lack of energy	Mild Moderate Severe Depression

Musculoskeletal & Calcium Metabolism

Mild Moderate Severe Neck pain	Mild Moderate Severe Foot/ankle pain	Mild Moderate Severe Shoulder pain
Mild Moderate Severe Joints injure easily	Mild Moderate Severe Muscle spasm	Mild Moderate Severe Bursitis/tendonitis
Mild Moderate Severe Kidney stones	Mild Moderate Severe Chiropractic adjustments	Mild Moderate Severe Back pain
Mild Moderate Severe Hip pain	Mild Moderate Severe Degenerative joint disease	Mild Moderate Severe Muscle pain
Mild Moderate Severe Numbness	Mild Moderate Severe Carpal tunnel syndrome	Mild Moderate Severe Osteoporosis
Mild Moderate Severe Knee pain	Mild Moderate Severe Hand/wrist pain	Mild Moderate Severe Joint stiffness
Mild Moderate Severe Muscle weakness	Mild Moderate Severe Tremors or shakiness	Mild Moderate Severe Balance difficulties
Mild Moderate Severe Recent dental cavities

Headaches

Mild Moderate Severe Migranes	Mild Moderate Severe Dull/pressure type	Mild Moderate Severe Wakes you from sleep
Mild Moderate Severe Stiff Neck	Mild Moderate Severe Backache	Mild Moderate Severe Jaw pops, locks, grinds
Mild Moderate Severe Teeth grinding	Mild Moderate Severe Orthopedic work recently	Mild Moderate Severe One side headaches

When did the headaches first begin? How log do they last? What helps releive them, What triggers them?

Neuropsycological

Mild Moderate Severe History of seizures	Mild Moderate Severe Attention deficit disorder	Mild Moderate Severe Depressed unmotivated
Mild Moderate Severe Poor memory	Mild Moderate Severe Poor concentration	Mild Moderate Severe Poor performance
Mild Moderate Severe Learning disorder	Mild Moderate Severe Very restless	Mild Moderate Severe Difficulty sleeping
Mild Moderate Severe Withdrawn socially	Mild Moderate Severe Resless mind	Mild Moderate Severe Suicidal thoughts

Miscellaneous

Mild Moderate Severe Catches colds easily'	Mild Moderate Severe Shingles	Mild Moderate Severe Toenail fungus
Mild Moderate Severe Cold/canker sores	Mild Moderate Severe Swollen lymph nodes	Mild Moderate Severe Yeast/bladder infections
Mild Moderate Severe Frequent bronchitis	Mild Moderate Severe Herpes	Mild Moderate Severe Plastic surgery
Mild Moderate Severe Bleeding gums	Mild Moderate Severe Loss of smell	Mild Moderate Severe Loss of taste

Dental History

Have you had orthodontic work done, had braces causing complications, mercury fillings, gingivitis or serious oriblem?