Jacina Facial Acupuncture Form 2020

1
Please answer this as honestly as possible. This information is confidential.
2
Name
First Name
Last Name
3
Email
example@example.com
4
Address
Street Address
Street Address Line 2
City
County
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number
Area Code
Phone Number
6
Age?
7
DOB
Date
Year
Month
Day
8
Emergency contact name & their relationship to you
9
Are you pregnant or trying to conceive?
YESNO
10
Have you had acupuncture before?
YESNO
11
Do you bruise easily?
YESNO
12
Are you taking cod liver oil as a supplement?
YESNO
13
Please describe your skin care routine
Huge
Large
Normal
Small
Ok
Ok
14
Do you wear sunscreen?
YESNO
15
Do you have a healthy diet?
YESNO
16
Please describe a typical day's food. Breakfast, lunch and dinner.
Huge
Large
Normal
Small
Ok
Ok
17
How many snacks do you have a day and what kind of snacks?
18
What areas of your face are you wishing to improve?* This field is required.
Eye area
smile lines
forehead
11'es
jaw line
crows feet
not listed
19
Please can you describe the main reason for your visit.
Huge
Large
Normal
Small
Ok
Ok
20
Have you had any recent Botox, fillers or plastic surgery? Please note months and years and areas. Mention if you have had any complications or reatctions?
Huge
Large
Normal
Small
Ok
Ok
21
Have you ever had any adverse reaction to any treatment or facial treatmente.g. every time I go to the dentist I faint.
Huge
Large
Normal
Small
Ok
Ok
22
Have you ever had any of the following health conditions
no
past
current
in my family
Heart Conditions
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Diabetes
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Respiratory Conditions
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
HIV/AIDS
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
TMJ / Jaw Pain
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Skin Condition
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Thyroid Condition
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
PMS
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Stroke
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Deep Vein Thrombosis
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Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Kidney Disorder
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Sprain/Strain/Fracture
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Arthritis
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Digestive Issues
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Epilepsy
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
High Blood Pressure
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Row 15, Column 2
Row 15, Column 3
Low Blood Pressure
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Cancer
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Neurological Issues
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Osteoporosis
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Row 19, Column 3
Dizziness/ Fainting
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
Row 20, Column 3
Haemophilia
Row 21, Column 0
Row 21, Column 1
Row 21, Column 2
Row 21, Column 3
Multiple Sclerosis
Row 22, Column 0
Row 22, Column 1
Row 22, Column 2
Row 22, Column 3
Spinal/ Head Injury
Row 23, Column 0
Row 23, Column 1
Row 23, Column 2
Row 23, Column 3
Hepatitis
Row 24, Column 0
Row 24, Column 1
Row 24, Column 2
Row 24, Column 3
Headaches/ Migraines
Row 25, Column 0
Row 25, Column 1
Row 25, Column 2
Row 25, Column 3
Contagious Illness
Row 26, Column 0
Row 26, Column 1
Row 26, Column 2
Row 26, Column 3
Wearing a Pacemaker
Row 27, Column 0
Row 27, Column 1
Row 27, Column 2
Row 27, Column 3
Endometriosis
Row 28, Column 0
Row 28, Column 1
Row 28, Column 2
Row 28, Column 3
Upcoming surgery?
Row 29, Column 0
Row 29, Column 1
Row 29, Column 2
Row 29, Column 3
Are you Pregnant?
Row 30, Column 0
Row 30, Column 1
Row 30, Column 2
Row 30, Column 3
Heart Conditions
Diabetes
Respiratory Conditions
HIV/AIDS
TMJ / Jaw Pain
Skin Condition
Thyroid Condition
PMS
Stroke
Deep Vein Thrombosis
Kidney Disorder
Sprain/Strain/Fracture
Arthritis
Digestive Issues
Epilepsy
High Blood Pressure
Low Blood Pressure
Cancer
Neurological Issues
Osteoporosis
Dizziness/ Fainting
Haemophilia
Multiple Sclerosis
Spinal/ Head Injury
Hepatitis
Headaches/ Migraines
Contagious Illness
Wearing a Pacemaker
Endometriosis
Upcoming surgery?
Are you Pregnant?
no
Row 0, Column 0
past
Row 0, Column 1
current
Row 0, Column 2
in my family
Row 0, Column 3
no
Row 1, Column 0
past
Row 1, Column 1
current
Row 1, Column 2
in my family
Row 1, Column 3
no
Row 2, Column 0
past
Row 2, Column 1
current
Row 2, Column 2
in my family
Row 2, Column 3
no
Row 3, Column 0
past
Row 3, Column 1
current
Row 3, Column 2
in my family
Row 3, Column 3
no
Row 4, Column 0
past
Row 4, Column 1
current
Row 4, Column 2
in my family
Row 4, Column 3
no
Row 5, Column 0
past
Row 5, Column 1
current
Row 5, Column 2
in my family
Row 5, Column 3
no
Row 6, Column 0
past
Row 6, Column 1
current
Row 6, Column 2
in my family
Row 6, Column 3
no
Row 7, Column 0
past
Row 7, Column 1
current
Row 7, Column 2
in my family
Row 7, Column 3
no
Row 8, Column 0
past
Row 8, Column 1
current
Row 8, Column 2
in my family
Row 8, Column 3
no
Row 9, Column 0
past
Row 9, Column 1
current
Row 9, Column 2
in my family
Row 9, Column 3
no
Row 10, Column 0
past
Row 10, Column 1
current
Row 10, Column 2
in my family
Row 10, Column 3
no
Row 11, Column 0
past
Row 11, Column 1
current
Row 11, Column 2
in my family
Row 11, Column 3
no
Row 12, Column 0
past
Row 12, Column 1
current
Row 12, Column 2
in my family
Row 12, Column 3
no
Row 13, Column 0
past
Row 13, Column 1
current
Row 13, Column 2
in my family
Row 13, Column 3
no
Row 14, Column 0
past
Row 14, Column 1
current
Row 14, Column 2
in my family
Row 14, Column 3
no
Row 15, Column 0
past
Row 15, Column 1
current
Row 15, Column 2
in my family
Row 15, Column 3
no
Row 16, Column 0
past
Row 16, Column 1
current
Row 16, Column 2
in my family
Row 16, Column 3
no
Row 17, Column 0
past
Row 17, Column 1
current
Row 17, Column 2
in my family
Row 17, Column 3
no
Row 18, Column 0
past
Row 18, Column 1
current
Row 18, Column 2
in my family
Row 18, Column 3
no
Row 19, Column 0
past
Row 19, Column 1
current
Row 19, Column 2
in my family
Row 19, Column 3
no
Row 20, Column 0
past
Row 20, Column 1
current
Row 20, Column 2
in my family
Row 20, Column 3
no
Row 21, Column 0
past
Row 21, Column 1
current
Row 21, Column 2
in my family
Row 21, Column 3
no
Row 22, Column 0
past
Row 22, Column 1
current
Row 22, Column 2
in my family
Row 22, Column 3
no
Row 23, Column 0
past
Row 23, Column 1
current
Row 23, Column 2
in my family
Row 23, Column 3
no
Row 24, Column 0
past
Row 24, Column 1
current
Row 24, Column 2
in my family
Row 24, Column 3
no
Row 25, Column 0
past
Row 25, Column 1
current
Row 25, Column 2
in my family
Row 25, Column 3
no
Row 26, Column 0
past
Row 26, Column 1
current
Row 26, Column 2
in my family
Row 26, Column 3
no
Row 27, Column 0
past
Row 27, Column 1
current
Row 27, Column 2
in my family
Row 27, Column 3
no
Row 28, Column 0
past
Row 28, Column 1
current
Row 28, Column 2
in my family
Row 28, Column 3
no
Row 29, Column 0
past
Row 29, Column 1
current
Row 29, Column 2
in my family
Row 29, Column 3
no
Row 30, Column 0
past
Row 30, Column 1
current
Row 30, Column 2
in my family
Row 30, Column 3
1 of 31
23
Please Elaborate any of the above here with dates and summary
Huge
Large
Normal
Small
Ok
Ok
24
Please describe any surgeries in the last 5 years.
25
Please note any of the following: prescription medication, over the counter medication or any other herbal or supplements you are currently taking.
Huge
Large
Normal
Small
Ok
Ok
26
Any Allergies (food, drugs, environmental)?
27
Do you smoke? If so how much and how often?
28
Do you drink alcohol? How many units and how often?
29
What is your daily intake of caffeine?
30
Fizzy drinks?
31
Recreational drugs?
32
Do you exercise? If so how often and what kind of activities
Huge
Large
Normal
Small
Ok
Ok
33
Have you had acupuncture before?
YESNO
34
What other kind of treatments do you do?
Huge
Large
Normal
Small
Ok
Ok
35
Do you have broken or ulcerated skin?
YESNO
36
Do you have a history of cold sores?
YESNO
37
Do you bruise easily?
YESNO
38
Do you sunbathe or use sun beds regularly?
YESNO
39
Do you have keloid scars/ moles or warts?
YESNO
40
Any skin allergies? If so when?
41
Have you seen a dermatologist? What was the reason?
42
What is your current skin care routine?
Huge
Large
Normal
Small
Ok
Ok
43
Can you rate your current energy levels out of 10?
Please enter a number
44
Energy Levels
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
45
Liver - GanLeaver blank if not applicable
Often
sometimes
occasionally
Irritability
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Row 0, Column 1
Row 0, Column 2
Frustration
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Depression
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Stress
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Emotional Eating
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Unfulfilled desires
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Blurred/ poor night vision
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Red/ dry / itchy eyes
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Headache / migraines
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Dizziness
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Feeling of lump in throat
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Muscle twitching spasm
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Neck / shoulder tension
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Brittle nails
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Sighing
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Sensation / Pain under ribs
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
PMS
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Genital itching, pain, rashes
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Irritability
Frustration
Depression
Stress
Emotional Eating
Unfulfilled desires
Blurred/ poor night vision
Red/ dry / itchy eyes
Headache / migraines
Dizziness
Feeling of lump in throat
Muscle twitching spasm
Neck / shoulder tension
Brittle nails
Sighing
Sensation / Pain under ribs
PMS
Genital itching, pain, rashes
Often
Row 0, Column 0
sometimes
Row 0, Column 1
occasionally
Row 0, Column 2
Often
Row 1, Column 0
sometimes
Row 1, Column 1
occasionally
Row 1, Column 2
Often
Row 2, Column 0
sometimes
Row 2, Column 1
occasionally
Row 2, Column 2
Often
Row 3, Column 0
sometimes
Row 3, Column 1
occasionally
Row 3, Column 2
Often
Row 4, Column 0
sometimes
Row 4, Column 1
occasionally
Row 4, Column 2
Often
Row 5, Column 0
sometimes
Row 5, Column 1
occasionally
Row 5, Column 2
Often
Row 6, Column 0
sometimes
Row 6, Column 1
occasionally
Row 6, Column 2
Often
Row 7, Column 0
sometimes
Row 7, Column 1
occasionally
Row 7, Column 2
Often
Row 8, Column 0
sometimes
Row 8, Column 1
occasionally
Row 8, Column 2
Often
Row 9, Column 0
sometimes
Row 9, Column 1
occasionally
Row 9, Column 2
Often
Row 10, Column 0
sometimes
Row 10, Column 1
occasionally
Row 10, Column 2
Often
Row 11, Column 0
sometimes
Row 11, Column 1
occasionally
Row 11, Column 2
Often
Row 12, Column 0
sometimes
Row 12, Column 1
occasionally
Row 12, Column 2
Often
Row 13, Column 0
sometimes
Row 13, Column 1
occasionally
Row 13, Column 2
Often
Row 14, Column 0
sometimes
Row 14, Column 1
occasionally
Row 14, Column 2
Often
Row 15, Column 0
sometimes
Row 15, Column 1
occasionally
Row 15, Column 2
Often
Row 16, Column 0
sometimes
Row 16, Column 1
occasionally
Row 16, Column 2
Often
Row 17, Column 0
sometimes
Row 17, Column 1
occasionally
Row 17, Column 2
1 of 18
46
Kidney - ShenLeaver blank if not applicable
Often
sometimes
occasionally
Frequent Urination
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Bladder Infection
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Loss of bladder control
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
waking at night to urinate
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Feeling cold easily
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Cold hands or feet
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Night sweats / hot flushes
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Low sex drive
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
High sex drive
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Loss of head hair
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Hearing problems
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Craving salty food
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Fearful
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Poor long term memory
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Ankle swelling
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
tinnitus
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Frequent Urination
Bladder Infection
Loss of bladder control
waking at night to urinate
Feeling cold easily
Cold hands or feet
Night sweats / hot flushes
Low sex drive
High sex drive
Loss of head hair
Hearing problems
Craving salty food
Fearful
Poor long term memory
Ankle swelling
tinnitus
Often
Row 0, Column 0
sometimes
Row 0, Column 1
occasionally
Row 0, Column 2
Often
Row 1, Column 0
sometimes
Row 1, Column 1
occasionally
Row 1, Column 2
Often
Row 2, Column 0
sometimes
Row 2, Column 1
occasionally
Row 2, Column 2
Often
Row 3, Column 0
sometimes
Row 3, Column 1
occasionally
Row 3, Column 2
Often
Row 4, Column 0
sometimes
Row 4, Column 1
occasionally
Row 4, Column 2
Often
Row 5, Column 0
sometimes
Row 5, Column 1
occasionally
Row 5, Column 2
Often
Row 6, Column 0
sometimes
Row 6, Column 1
occasionally
Row 6, Column 2
Often
Row 7, Column 0
sometimes
Row 7, Column 1
occasionally
Row 7, Column 2
Often
Row 8, Column 0
sometimes
Row 8, Column 1
occasionally
Row 8, Column 2
Often
Row 9, Column 0
sometimes
Row 9, Column 1
occasionally
Row 9, Column 2
Often
Row 10, Column 0
sometimes
Row 10, Column 1
occasionally
Row 10, Column 2
Often
Row 11, Column 0
sometimes
Row 11, Column 1
occasionally
Row 11, Column 2
Often
Row 12, Column 0
sometimes
Row 12, Column 1
occasionally
Row 12, Column 2
Often
Row 13, Column 0
sometimes
Row 13, Column 1
occasionally
Row 13, Column 2
Often
Row 14, Column 0
sometimes
Row 14, Column 1
occasionally
Row 14, Column 2
Often
Row 15, Column 0
sometimes
Row 15, Column 1
occasionally
Row 15, Column 2
1 of 16
47
Lung - FeiLeaver blank if not applicable
Often
sometimes
occasionally
dry cough
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
phlegmy cough
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
nasal discharge /drip
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
sinus infection /congestion
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
itchy painful throat
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
dry mouth / nose / throat
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
skin rashes / hives
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
snoring
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
grief / sadness
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
shortness of breath
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
allergies / asthma
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
weak immune system
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
alternate fevers / chills
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
dry cough
phlegmy cough
nasal discharge /drip
sinus infection /congestion
itchy painful throat
dry mouth / nose / throat
skin rashes / hives
snoring
grief / sadness
shortness of breath
allergies / asthma
weak immune system
alternate fevers / chills
Often
Row 0, Column 0
sometimes
Row 0, Column 1
occasionally
Row 0, Column 2
Often
Row 1, Column 0
sometimes
Row 1, Column 1
occasionally
Row 1, Column 2
Often
Row 2, Column 0
sometimes
Row 2, Column 1
occasionally
Row 2, Column 2
Often
Row 3, Column 0
sometimes
Row 3, Column 1
occasionally
Row 3, Column 2
Often
Row 4, Column 0
sometimes
Row 4, Column 1
occasionally
Row 4, Column 2
Often
Row 5, Column 0
sometimes
Row 5, Column 1
occasionally
Row 5, Column 2
Often
Row 6, Column 0
sometimes
Row 6, Column 1
occasionally
Row 6, Column 2
Often
Row 7, Column 0
sometimes
Row 7, Column 1
occasionally
Row 7, Column 2
Often
Row 8, Column 0
sometimes
Row 8, Column 1
occasionally
Row 8, Column 2
Often
Row 9, Column 0
sometimes
Row 9, Column 1
occasionally
Row 9, Column 2
Often
Row 10, Column 0
sometimes
Row 10, Column 1
occasionally
Row 10, Column 2
Often
Row 11, Column 0
sometimes
Row 11, Column 1
occasionally
Row 11, Column 2
Often
Row 12, Column 0
sometimes
Row 12, Column 1
occasionally
Row 12, Column 2
1 of 13
48
Heart - XinLeave blank if not applicable
Often
sometimes
occasionally
Palpitations
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Chest pain / tightness
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Insomnia / sleep problems
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Restlessness
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Easily agitated
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Vivid dreams
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Lack of Joy in life
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Forgetfulness
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Aversion to heat
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Bitter taste in mouth
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Tongue/ mouth ulcers
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Palpitations
Chest pain / tightness
Insomnia / sleep problems
Restlessness
Easily agitated
Vivid dreams
Lack of Joy in life
Forgetfulness
Aversion to heat
Bitter taste in mouth
Tongue/ mouth ulcers
Often
Row 0, Column 0
sometimes
Row 0, Column 1
occasionally
Row 0, Column 2
Often
Row 1, Column 0
sometimes
Row 1, Column 1
occasionally
Row 1, Column 2
Often
Row 2, Column 0
sometimes
Row 2, Column 1
occasionally
Row 2, Column 2
Often
Row 3, Column 0
sometimes
Row 3, Column 1
occasionally
Row 3, Column 2
Often
Row 4, Column 0
sometimes
Row 4, Column 1
occasionally
Row 4, Column 2
Often
Row 5, Column 0
sometimes
Row 5, Column 1
occasionally
Row 5, Column 2
Often
Row 6, Column 0
sometimes
Row 6, Column 1
occasionally
Row 6, Column 2
Often
Row 7, Column 0
sometimes
Row 7, Column 1
occasionally
Row 7, Column 2
Often
Row 8, Column 0
sometimes
Row 8, Column 1
occasionally
Row 8, Column 2
Often
Row 9, Column 0
sometimes
Row 9, Column 1
occasionally
Row 9, Column 2
Often
Row 10, Column 0
sometimes
Row 10, Column 1
occasionally
Row 10, Column 2
1 of 11
49
Stomach - PiLeave blank if not applicable
Often
sometimes
occasionally
Heavy head /body
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
fatigue after food
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
difficulty waking up
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
water retention
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
muscle tiredness / weakness
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
bruise easily
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
unusual bleeding nose /stools
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
bad breath
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
poor appetite
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
increased appetite
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
sweet cravings
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
poor digestions
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
nausea / vomiting
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
bloating / gas
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
haemorrhoids
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
constipation
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
loose stools
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
alternate loose stools constipation
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
abdominal pain
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
intestinal pain / cramping
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
heartburn
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
pensive / overthinking
Row 21, Column 0
Row 21, Column 1
Row 21, Column 2
overweight
Row 22, Column 0
Row 22, Column 1
Row 22, Column 2
foggy mind
Row 23, Column 0
Row 23, Column 1
Row 23, Column 2
yeast infection
Row 24, Column 0
Row 24, Column 1
Row 24, Column 2
aversion to cold
Row 25, Column 0
Row 25, Column 1
Row 25, Column 2
cold nose
Row 26, Column 0
Row 26, Column 1
Row 26, Column 2
increased thirst
Row 27, Column 0
Row 27, Column 1
Row 27, Column 2
prefer warm drinks
Row 28, Column 0
Row 28, Column 1
Row 28, Column 2
prefer cold drinks
Row 29, Column 0
Row 29, Column 1
Row 29, Column 2
sweat easily
Row 30, Column 0
Row 30, Column 1
Row 30, Column 2
Heavy head /body
fatigue after food
difficulty waking up
water retention
muscle tiredness / weakness
bruise easily
unusual bleeding nose /stools
bad breath
poor appetite
increased appetite
sweet cravings
poor digestions
nausea / vomiting
bloating / gas
haemorrhoids
constipation
loose stools
alternate loose stools constipation
abdominal pain
intestinal pain / cramping
heartburn
pensive / overthinking
overweight
foggy mind
yeast infection
aversion to cold
cold nose
increased thirst
prefer warm drinks
prefer cold drinks
sweat easily
Often
Row 0, Column 0
sometimes
Row 0, Column 1
occasionally
Row 0, Column 2
Often
Row 1, Column 0
sometimes
Row 1, Column 1
occasionally
Row 1, Column 2
Often
Row 2, Column 0
sometimes
Row 2, Column 1
occasionally
Row 2, Column 2
Often
Row 3, Column 0
sometimes
Row 3, Column 1
occasionally
Row 3, Column 2
Often
Row 4, Column 0
sometimes
Row 4, Column 1
occasionally
Row 4, Column 2
Often
Row 5, Column 0
sometimes
Row 5, Column 1
occasionally
Row 5, Column 2
Often
Row 6, Column 0
sometimes
Row 6, Column 1
occasionally
Row 6, Column 2
Often
Row 7, Column 0
sometimes
Row 7, Column 1
occasionally
Row 7, Column 2
Often
Row 8, Column 0
sometimes
Row 8, Column 1
occasionally
Row 8, Column 2
Often
Row 9, Column 0
sometimes
Row 9, Column 1
occasionally
Row 9, Column 2
Often
Row 10, Column 0
sometimes
Row 10, Column 1
occasionally
Row 10, Column 2
Often
Row 11, Column 0
sometimes
Row 11, Column 1
occasionally
Row 11, Column 2
Often
Row 12, Column 0
sometimes
Row 12, Column 1
occasionally
Row 12, Column 2
Often
Row 13, Column 0
sometimes
Row 13, Column 1
occasionally
Row 13, Column 2
Often
Row 14, Column 0
sometimes
Row 14, Column 1
occasionally
Row 14, Column 2
Often
Row 15, Column 0
sometimes
Row 15, Column 1
occasionally
Row 15, Column 2
Often
Row 16, Column 0
sometimes
Row 16, Column 1
occasionally
Row 16, Column 2
Often
Row 17, Column 0
sometimes
Row 17, Column 1
occasionally
Row 17, Column 2
Often
Row 18, Column 0
sometimes
Row 18, Column 1
occasionally
Row 18, Column 2
Often
Row 19, Column 0
sometimes
Row 19, Column 1
occasionally
Row 19, Column 2
Often
Row 20, Column 0
sometimes
Row 20, Column 1
occasionally
Row 20, Column 2
Often
Row 21, Column 0
sometimes
Row 21, Column 1
occasionally
Row 21, Column 2
Often
Row 22, Column 0
sometimes
Row 22, Column 1
occasionally
Row 22, Column 2
Often
Row 23, Column 0
sometimes
Row 23, Column 1
occasionally
Row 23, Column 2
Often
Row 24, Column 0
sometimes
Row 24, Column 1
occasionally
Row 24, Column 2
Often
Row 25, Column 0
sometimes
Row 25, Column 1
occasionally
Row 25, Column 2
Often
Row 26, Column 0
sometimes
Row 26, Column 1
occasionally
Row 26, Column 2
Often
Row 27, Column 0
sometimes
Row 27, Column 1
occasionally
Row 27, Column 2
Often
Row 28, Column 0
sometimes
Row 28, Column 1
occasionally
Row 28, Column 2
Often
Row 29, Column 0
sometimes
Row 29, Column 1
occasionally
Row 29, Column 2
Often
Row 30, Column 0
sometimes
Row 30, Column 1
occasionally
Row 30, Column 2
1 of 31
50
what is your occupation / daily routine?
51
Bowels
yes
no
mixed
Do you have regualr bowel movements?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
are they well formed
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
difficult to pass stools?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
are you a light sleeper
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Do you get 7 hours a night?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
do you have vivid dreams?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
do you wake in the night?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
is is easy to get back to sleep?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Urinary frequency?
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Any urinary urgency?
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Urinary burning?
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Urinary dribbling?
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Urinary retention?
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
frequent UTI s?
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Do you drink water through out the day?
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Do you have regualr bowel movements?
are they well formed
difficult to pass stools?
are you a light sleeper
Do you get 7 hours a night?
do you have vivid dreams?
do you wake in the night?
is is easy to get back to sleep?
Urinary frequency?
Any urinary urgency?
Urinary burning?
Urinary dribbling?
Urinary retention?
frequent UTI s?
Do you drink water through out the day?
yes
Row 0, Column 0
no
Row 0, Column 1
mixed
Row 0, Column 2
yes
Row 1, Column 0
no
Row 1, Column 1
mixed
Row 1, Column 2
yes
Row 2, Column 0
no
Row 2, Column 1
mixed
Row 2, Column 2
yes
Row 3, Column 0
no
Row 3, Column 1
mixed
Row 3, Column 2
yes
Row 4, Column 0
no
Row 4, Column 1
mixed
Row 4, Column 2
yes
Row 5, Column 0
no
Row 5, Column 1
mixed
Row 5, Column 2
yes
Row 6, Column 0
no
Row 6, Column 1
mixed
Row 6, Column 2
yes
Row 7, Column 0
no
Row 7, Column 1
mixed
Row 7, Column 2
yes
Row 8, Column 0
no
Row 8, Column 1
mixed
Row 8, Column 2
yes
Row 9, Column 0
no
Row 9, Column 1
mixed
Row 9, Column 2
yes
Row 10, Column 0
no
Row 10, Column 1
mixed
Row 10, Column 2
yes
Row 11, Column 0
no
Row 11, Column 1
mixed
Row 11, Column 2
yes
Row 12, Column 0
no
Row 12, Column 1
mixed
Row 12, Column 2
yes
Row 13, Column 0
no
Row 13, Column 1
mixed
Row 13, Column 2
yes
Row 14, Column 0
no
Row 14, Column 1
mixed
Row 14, Column 2
1 of 15
52
Do you enjoy what you do daily?
53
how often are you working?
54
Do you see daylight in your job / day to day?
55
Is you day to day stressful?
56
If you are stressed please specify why / who / where (personal or work)?
Huge
Large
Normal
Small
Ok
Ok
57
Do you consider yourself to be in good general health?
58
How often have you taken either antibiotics or steroids in the last 5 years?
59
How much do you drink a day? Do you prefer warm or cold drinks? Do you sip or gulp?
60
Have you ever been diagnosed with any of the following?
STD
Polyps
Pelvic inflammatory disease
Pelvic Adhesions
Uterine fibroids
Prolapsed Uterus
frequent yeast infections
Any cervical biopsy /operations
Any abnormal smear
Is your smear up to date?
Endometriosis
PCO or PCOS
Had an IUD
Take or taken the Pill
Other
61
About your periods
I am still menstruating
I think I am peri menopausal
I get PMS
I get pain before my period
I get pain during my period
I get paid after my period
the pain is stabbing
the pain is cramping
the pain is dull
the pain is heavy
the pain is on /off
62
Pre-menstrual Symptoms
breast tenderness
cramps
acne
bloating
headaches
change in bowel
nausea
moodiness
fatigue
night sweats
sleep disturbances
63
what relieves menstrual pain?
64
Have you ever suffered from depression?
YESNO
65
Have you ever had any medical diagnosis for mental health conditions? If so when.
Huge
Large
Normal
Small
Ok
Ok
66
Have you ever had or suffered with suicidal thoughts?
67
Any paranormal activity experiences or significant life events that have left a mark?seeing ghosts
Huge
Large
Normal
Small
Ok
Ok
68
Have you ever experienced any abuse or victimisation?
Huge
Large
Normal
Small
Ok
Ok
69
Is there anything else you feel is important or relevant?
Huge
Large
Normal
Small
Ok
Ok
70
If you took the Pill - for how long and when did you stop, or are you still taking it?
71
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