Chinese Herbalist, Acupuncture Clinic in Chicago, Northbrook, IL

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Make an appointment
- Please call one of our TCM/acupuncture clinic in Chicago, Northbrook or Westmont to make an appointment with a practitioner.

Chicago office Tel: 312-842-2775	Westmont office Tel: 630-789-2350	Northbrook office Tel: 847-770-6295
2131 S. Archer Ave. #B Chicago IL 60616 Driving Directions Mon, Thu: 9:15am-6:30pm Tue-Wed: 9:15am-5:30pm Fri: 9:15-5:30pm Sat: 9:15am-1:00pm Sun closed	665 Pasquinelli, # 203 Westmont, IL 60559 Driving Directions Mon: 9:30am-5:30pm Tue: 9:30am-8:00pm Wed-Fri: 9:30am-5:30pm Sat: 10:30am-4:30pm Sun: 9:30am-6:00pm	3100 Dundee Rd. # 202 Northbrook, IL 60062 Driving Directions Tue & Sat:10:00am-6:00pm Wed & Fri: 11:00am-7:00pm Mon, Thu, Sun closed

Consultation Form (For first time patients only)

Once all of your questions and concerns about Traditional Chinese Medicine have been addressed, be sure to call and schedule an appointment for further consultation. After you call and make an appointment, please complete and submit this online form at least 2 business days before your appointment with your Chinese herbalist or acupuncturist in Westmont, Northbrook or Chicago. If it is inside of 2 business days to your appointment, you can download our Consultation Form (You will need Acrobat Reader to view or print this form in Portable Document Format (PDF). PostScript files (.ps) may be printed by copying them to a PostScript-capable printer). Fill it out and bring it to the office when you come for your first visit for acupuncture in Northbrook, IL or any other location, or mail or fax the form to us. For mail or fax information, please check Contact Us.

Consultation Form (All * fields are required)

Appointment With:*

Chicago Office Westmont Office Northbrook Office

Phone Consultation (Give best time to reach you)

Appointment Date:* (mm/dd/yy)

Time:* (00:00)

Herbalist:*

First Name:*

Last Name:*

Age:*

Sex:* Male Female

Address:*

City:*

State:* Zip:*

E-mail:*

Phone(home):* -

Phone(work): -

Referral:

Occupation:

Below, describe all of your complaints, how long you have had them and how you are treating them. Be sure to mention any drugs, vitamin supplements. or other medicinal substances you are taking.

Complaint 1:	How long?	Treatment/Medication

Complaint2 :	How long?	Treatment/Medication

Complaint3 :	How long?	Treatment/Medication

Complaint4 :	How long?	Treatment/Medication

Complaint5 :	How long?	Treatment/Medication

Brief Health History: (list major diseases, surgeries, ect.)

How many times per year do you get a cold or the flu?

Diet:
(summarize how you eat; list any special diet such as high protein, raw food, ect.)

Family Medical History:

Emotions:

Normal

Problem

depression

sadness

panic attack

sensitive

worries

overly excited

angry

anxiety

Describe:

Energy:

Normal

Problem

low

up & down

exhausted

hyperactive

nervous energy

abundant

Describe:

Sleep Pattern:

Normal

Insomnia

Falling asleep:

sometimes
difficult

sometimes
very difficult

sleepy in
daytime

always difficult

always
very difficult

take naps

Waking up:

times per night

wake up too early

wake up at night and cannot go back to sleep again

Sleep Quality:

Deep

Light

Bad

many dreams

bad dreams

grinding teeth

talking in sleep

other

Describe:

Menstrual Cycle:

Regular Irregular

Age of onset:

Date of last period: (mm/dd/yy)

Days per cycle:

Days it lasts:

Color: pale red

dark red

bright red

purplish

Were there clot? Yes

Menstrual Pain: Yes

before flow

during flow

after flow

abdomen

back

breast

Emotion around period: Normal Abnormal

before flow

during flow

after flow

depression

irritability

anger

sadness

crying

other

Describe:

Temperature:

Normal

Abnormal

feel cold easily

cold hands

cold feet

feel hot easily

alternating hot & cold

hot flash

sensitive to weather changes

Describe:

Sweating:

Normal

Abnormal

too easily

too much

difficult

too little

night sweats

other

Describe:

Sensitivity and Allergy: Yes

Temperature:

cold

hot

dampness

light

noise

airborn
particles

food

drugs

other

Describe:

Appetite and Digestion: Normal

Abnormal

rapid
hungering

poor appetite

nausea

anorexia

hungry, but
no desire to eat

bloating

gas

other

Describe:

Bowel Movement: Normal

Abnormal

Time of day:

constipation

diarrhea

loose

watery

incomplete

hard and dry

strong smell

with mucous

with blood

other

Describe:

Body Weight:

Normal

Overweight

Underweight

If overweight:

How many pounds would you like to lose?

How many years ago did you first start to gain weight?

Are you following a weight control program at this time?
Yes No

Describe:

Drinking:

Normal

Abnormal

thirsty

dry mouth

dry mouth but no desire to drink

drink a lot

not thirsty, but drink a lot of water anyway

Describe:

Urination:

Normal

Abnormal

frequent

urgent

burning

painful

cloudy

dark color

foul smell

bloody

difficult

retention

other

Number of times per day:

Number of times per night:

Describe:

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