Free Online Stress Survey

TCM (Traditional Chinese Medicine) uses many different symptoms to diagnose a person's pathology. It is based on a holistic, energetic conception of the human being. Please fill out the questionnaire as completely as possible. Also please download and complete these initial health history forms. By completing these forms you will save & maximize time when you come in for your first visit.
 

Some questions may seem unrelated to the condition you are seeking help for. You may even have another condition that you consider to be unrelated to the one you are seeking help for today. However, in the holistic perspective of TCM, there are many interconnections within the living organism that are not seen by the Western model. Without TCM training, it is difficult to tell what is and isn't relevant to your treatment and pathology. Also, when a TCM doctor treats you, he or she treats your whole being, not just a single outstanding condition. Therefore, the more information you can provide in this online consultation, the better Dr. Zhou will be able to help you.

In most cases, Dr. Zhou will contact you by phone within 24 hours to discuss your condition and the ways in which TCM can be of help to you.
Your Name:  required
Address:
Phone Number:
Cell Number (use period for spacing):   required
E-mail Address:   required
Occupation:
Age:
Sex:
Main Concern:
   
1 Check any of the following symptoms you have experienced in the past 6 months
 
Headaches/Tension Low Back Pain Knee Pain Muscle/Joint Pain
Fatigue/Tired Neck Pain Ankle/Foot Pain Numbness/Tingling in Arms or Hands
Weight Trouble Wrist/Hand Pain Menopause/Hot Flashes Tension Across Top Of Shoulders
IBS/Acid Reflux Elbow Pain Ringing in Ears Numbness/Tingling in Legs or Feet
Difficulty Sleeping Shoulder Pain Nervousness Pain Between Shoulder Blades
Irritability Hip Pain Dizziness Pain Anywhere In The Body
Depression Acne Allergies Irregular Period/PMS
Allergies/Sinus Other Digestive Problems Smoking Chest Pain/Irregular Heart Beat
Which of the above bothers you the most?
How long have you been bothered by the condition?
Describe how it feels or affects you when it is at its worst.
What medications or supplements are you currently taking?
2 Does this cause you to be: 3 Does this affect your work? 4 Does this affect your life?
           
Moody Decision Making Lose Patience with Spouse or Children
Irritable Poor Attitude Restricted Household Duties
Sleeping with Interruptions Decreased Productivity Hinder Ability To Exercise or Participate in Sports
Restricted on Daily Activities Exhausted at End of Day Interferes with Ability to Participate in Hobbies or Other Desired Activities
    Unable to Work Long Hours    
           

If you checked any of the above items, your organs may not be functioning properly and your body may be out of balance.

ACUPUNCTURE AND TRADITIONAL CHINESE MEDICINE MAY HELP YOU because they gently and naturally treat the body to remove the stress and imbalance that cause health problems.

WOULD YOU LIKE TO GET RID OF THE PROBLEM? Yes No

 

If your answer is YES, there are several alternatives available to you. Please let us know how you would like to learn more.