Appointment
Login

Evaluation Form

Name*
Phone (Home)*
Phone (Work)*
Street*
Age*
Height*
Weight*
City*
Occupation*
Sex*
State*
Zip*
Date of Birth*
Place of Birth*
Marital Status*
Family Physician*
Social Security Nº*
Drivers License*
In Emergency Notify*
Mobile*
Referred By*
Have you been treated by acupuncture before?*
Main problem(s) with which you would like help. Problem or Disease*
How long ago did this problem begin (be specific)*
To what extent does this problem interfere with your daily activities (work, sleep, sex, etc.)?*
How long ago did this problem begin (be specific)*
Have you been given a diagnosis for this problem?*
What kind of treatment have you tried?*
Past Medical History (please include dates)*
Significant Illnesses:*
Surgeries*
Significant Trauma*
Birth History*
Allergies*
Family Medical History
Occupation
Occupation*
Medicines taken within the last two months (Include vitamins, over-the-counter drugs, herbs, etc)*
Are you now or have you ever been on a restricted diet? What kind?*
Please describe your average daily diet: Morning | Afternoon | Evening *
How many packs of cigarettes a day do you smoke?*
How much coffee, tea or cola do you drink per week?*
How much alcohol do you drink per week?*
Please describe any use of drugs for non-medical purposes:*
General
Skin and Hair
Head, Eyes, Ears, Nose and Throat
Cardiovascular
Gastrointestinal
Genito-Urinary
Do you wake up to urinate?*
Any particular color to your urine?*
Any other problems with your genital or urinary system?*
Pregnancy and Gynecology
Number of pregnancies*
Number of Births*
Premature Births*
Miscarriages*
Abortions*
Age at first menses*
Period between menses*
Duration*
First date of last menses*
Musculoskeletal
Any other joint or bone problems?*
Neuropsychological
Have you ever been treated for emotional problems?*
Have you ever considered or attempted suicide?*
Any other neurological or psychological problems?*
Which of the following symptoms apply at this time? 1 being minor and 5 being major problem
Mental Function
Decreased concentration*
Decreased sociability*
Decreased short term memory*
Decreased long term memory*
Decreased personal drive*
Anxiety*
Decreased confidence*
Increased stress levels*
Increased mood swings*
Depression*
Nervousness*
Difficulty Sleeping*
Physical Function
Decreased sense of well being*
Decreased skin tone*
Muscle weakness*
Joint pain*
Joint pain during exercise*
Muscle aches and pains*
Back pain*
Increased fatigue*
Poor wound healing*
Sagging or loose skin*
Nipple sensitivity*
Decreased in ability/frequency to perform sexually*
Decreased in sexual desire*
Increased fat deposits*
Increased muscle deterioration*
Decreased energy*
Decreased exercise tolerance*
Discomfort during intercourse*
Decreased endurance*
Thinning and/or dry skin*
Thinning or loss of hair*
Increased bone fractures*
Temperature intolerance*
Physical exhaustion*
Heavy menstrual cycle*
Decrease in the number of morning erections*
Decrease in testicle size*
Decreased sperm count*
Gynocomastia (Male breast)*
Hypertension*
Prostate cancer*
Carpal Tunnel Syndrome*
Other form of cancer*
Osteoporosis*
Do you have any other major symptoms?*
Newsletter

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.

Useful Links
Follow Us
Reach Us
  • infokoreme@gmail.com
  • (877) 7KOREME

© 2024 KoreMe Anti-Aging™ All Rights Reserved.

Website Managed By Web Brilliant