You can always press Enter⏎ to continue
CAREGIVER QUESTIONARE - AFTER EACH TREATMENT

CAREGIVER QUESTIONARE - AFTER EACH TREATMENT

Hi there, please fill out and submit this form.
8Questions

Accessibility

Enabled Form

Language
  • English (UK)
  • Hebrew
  • Arabic‬‎
  • 1
    Press
    Enter
  • 2
    Press
    Enter
  • 3
    -
    Pick a Date
    Press
    Enter
  • 4
    Press
    Enter
  • 5
    For Chinese medicine, please choose from the selection box. For other treatment methods, please type in the free text field.
    Please Select
    • Please Select
    • QI & Blood Stagnation in Lung Meridian
    • QI & Blood Stagnation in Large Intestine Meridian
    • QI & Blood Stagnation in Stomach Meridian
    • QI & Blood Stagnation in Spleen Meridian
    • QI & Blood Stagnation in Heart Meridian
    • QI & Blood Stagnation in Small Intestine Meridian
    • QI & Blood Stagnation in Bladder Meridian
    • QI & Blood Stagnation in Kidney Meridian
    • QI & Blood Stagnation in Pericardium Meridian
    • QI & Blood Stagnation in Triple Heater Meridian
    • QI & Blood Stagnation in Gall Bladder Meridian
    • QI & Blood Stagnation in Liver Meridian
    • Heart Qi Deficiency
    • Heart Yang Deficiency
    • Heart Yin Deficiency
    • Heart Blood Deficiency
    • Heart Fire
    • Liver Yin Deficiency
    • Liver Blood Deficiency
    • Liver Qi stagnation
    • Liver Yang Rising
    • Liver Fire
    • Liver Damp Heat
    • Liver Cold Stagnation
    • Liver Invading Spleen
    • Liver Invading Stomach
    • Lung Qi Deficiency
    • Lung Yin Deficiency
    • Lung Dryness
    • Lung Heat
    • Lung Damp-Phlegm
    • Spleen Qi Deficiency
    • Spleen Yang Deficiency
    • Spleen Qi Sinking
    • Spleen not Controlling Blood
    • Spleen Dampness
    • Kidney Yang Deficiency
    • Kidney Yin Deficiency
    • Kidney Qi Deficiency
    • Kidney Failing to Receive Qi
    • Stomach Qi Deficiency
    • Stomach Yin Deficiency
    • Stomach Deficient and Cold
    • Stomach Rebellious Qi
    • Stomach Fire
    • Small Intestine Qi Pain
    • Small Intestine Heat
    • Large Intestine Heat
    • Large Intestine Damp-Heat
    • Large Intestine Dryness
    • Gall Bladder Damp-Heat
    • Gall Bladder Deficiency
    • Bladder Damp-Heat
    • Bladder Deficient and Cold
    Press
    Enter
  • 6
    Only fill in for the treatment methods performed.
    • Acupuncture
    • Chinese Herbs
    • Hydrotherapy
    • Massage
    • Naturopathy
    • Osteopathy
    • Reflexology
    • Shiatsu
    • Tuina
    • Western Herbs
    Therapeutic principle of acupuncture
    • Therapeutic principle of acupuncture
    • Move Qi & Blood in Lung Meridian
    • Move Qi & Blood in Large Intestine Meridian
    • Move Qi & Blood in Stomach Meridian
    • Move Qi & Blood in Spleen Meridian
    • Move Qi & Blood in Heart Meridian
    • Move Qi & Blood in Small Intestine Meridian
    • Move Qi & Blood in Bladder Meridian
    • Move Qi & Blood in Kidney Meridian
    • Move Qi & Blood in Pericardium Meridian
    • Move Qi & Blood in Triple Heater Meridian
    • Move Qi & Blood in Gall Bladder Meridian
    • Move Qi & Blood in Liver Meridian
    • Disperse Dampness
    • Disperse Phlegm
    • Disperse Cold
    • Disperse Heat
    • Disperse Fire
    • Disperse Wind
    • Tonify Qi
    • Tonify Blood
    • Tonify Yin
    • Tonify Yang
    • Lower Yang
    • Lower Qi
    • Rise Qi
    • Move Qi Stagnation
    • Moisten Dryness
    • Warm Yang
    What Herbs were recommended ?
    • What Herbs were recommended ?
    • Chinese Herbs
    • Western Herbs
    • None
    Press
    Enter
  • 7
    From 1 the lowest to 10 the highest. If not applicable, select "not applicable"
    Intensity of symptoms
    • Intensity of symptoms
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10
    • not applicable
    Ability to perform compromised operations due to the symptoms
    • Ability to perform compromised operations due to the symptoms
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10
    • Not applicable
    Intensity of pain
    • Intensity of pain
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10
    • Not applicable
    Clients general mood
    • Clients general mood
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10
    • Not applicable
    Ability to Work
    • Ability to Work
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10
    • Not applicable
    Press
    Enter
  • 8
    • Huge
    • Large
    • Normal
    • Small
    Ok
    quoteCreated with Sketch.
    Ok
    Press
    Enter
  • Should be Empty:
Question Label
1 of 8See AllGo Back
close