HEALTH APPRAISAL FORMS
WOMEN'S FERTILITY HISTORY FORMS
WOMEN'S VOYAGE OF DISCOVERY
We provide you with forms to print out and fill in at your convenience. You are welcome to come in and fill them out in our office, however, this may be easier for you. Bring written reports of your condition to assist our efforts addressing your health concerns. If you have any questions, please call our office and we'll be happy to help you.
708.445.2000
1105 Holley Ct. Oak Park IL 60301
This is your initial form to print and fill out at your leisure.
Many answers will provide a clearer picture of contributing factors to your condition and allow us to better assess what traditional Chinese medical strategy to apply. Remember, acupuncture is multi-faceted, involving therapeutic exercises,like yoga, tai chi, qi gong, and simple stretching routines specific to your needs. Diet is to be considered always. We may suggest an herbal formula or supplements to boost your energy, calm your spirit or mitigate your pain. Feel free to call with any questions and we will schedule a convenient time for your initial acupuncture session with us.
This form provides important information to help us determine the best protocols for your condition. There are a myriad of gynecological conditions we treat with acupuncture and this information is absolutely necessary. Please take your time filling out the details and bring this and any additional pertinent information we can copy and have in your file. Call with any questions you may have.
This form helps determine your personal "Patterns of Disharmony"
A phrase we use in traditional Chinese medicine akin to Diagnosis.
You may have more than one so do not be alarmed. Most of us do. Simply check the descriptions that relate to you and bring in the form so we can go over it together and answer any questions you may have. The book this questionnaire was derived from is available at our office and we recommend you reading it.
And, please, if you have any pressing concerns about the information we are inquiring about, call us for a clear explanation.
Kuan Yin
Depicted holding a baby representing her role of
Mother Goddess,
mother of all humans
and protector of children.
#1
#2
#3
We derived questionnaire #3 from this book.
Check it out, order it, or you can
pick up a copy at our office
"Diet and lifestyle changes, blood flow and meditative exercises, herbal supplementation, and acupoint stimulation are the most effective elements of TCM for improving your fertility status."
~ Randine Lewis, Ph.D.
HEALTH FORMS
FOR YOU TO
PRINT AND BRING
IN TO OUR OFFICE
