Acupuncture First Name*Last Name*Date* Date Format: MM slash DD slash YYYY Have you had acupuncture before?*yesnoPlease explain the specific reason for you seeking Acupuncture at our center, including the date of onset, previous treatments sought for this condition, severity, etc.Primary Condition*Secondary ConditionOther Condition(s)Nutritional QuestionsDo you want to lose weight?yesnoIf yes, how much?Do you have regular eating habits?Are you vegetarian?vegan?special diet?Do you have any particular food cravings?Are you generally thirsty?Please select which you prefer? cold food hot food cold drink hot drink Which of the following do you consume regularly? Please select all that apply. white flour white rice white bread white sugar soy products green leafy vegetables fatty foods salty foods caffeinated beverages alcohol tobacco Other Important Questions What is your favorite season or climate?When do you typically go to sleep and wake up?Describe your quality of sleep? i.e. do you dream a lot?How is your energy level?Do you experience mood fluctuations?Do you get nervous a lot?Are you under a lot of stress?If yes, please describe.Do you ever feel a lump in your throat?Do you experience tightness in your chest?Have you ever been anemic?yesnoIf yes, when?Are you depressed?Are you fearful?Do you feel cold when other people don't?If you are a man, what is the condition of your prostate gland? Questions for Female Patients Please describe briefly your menstrual cycle and/or menopause.If you are still menstruating, please select the color of menstrual blood: light red dark red orange pink other Do you suffer from cramps?yesnoIf yes, are they prior, during, or after your period?Do you have menstrual clots?yesnoIs your menstrual flow light, moderate, or heavy?How many days does your cycle last?How many days between your cycles?If you experience PMS, please describe the symptoms, i.e. cramping, depression, bloating, headaches, mood swings, ect.