7/25/2019 Questionnaire - fillable.pdf

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Dr. William G. von Peters, O.M.D., N.M.D., Ph.D.Licensed in Acupuncture and Oriental MedicineProfessor National Center for Preventive Medicine - Moscow

Visiting Professor Heilongjiang University of Chinese MedicineRt.4, Box 93

Fairmont WV 26554

304-277-7104

J M J

Name____________________________________________________Phone:___________________________DOB:____________

Address:_________________________________________________________ City/State/Zip_______________________________

Age:_____________Sex: ___M ___F Weight: _______ Marital Status:________________ Pregnant?___Yes ___No ___N/A

Race:___Caucasian ___African American ___Hispanic ___Oriental ___Native American ___Other:_____________________

Occupation:_______________________________________Phone:___________________________Blood Type: ______________

Referred by: _________________________________ Natural Hair color: __Blonde __Brown __Black __Grey __Red __Other

Shampoo: _________________________________________Other Hair Preparations:____________________________________

Are you currently on prescribed medication? If so, list w/dosages and name of prescribing physician:

1)____________________________________________________ 3)___________________________________________________

2)____________________________________________________ 4)___________________________________________________

The health challenges I am most concerned about are:

____________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

Signed: __________________________________________________________________ Date: ______________________

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SECTION 1-Conditions

Place the correct code on those conditions that you have experienced/been diagnosed as having:

1=Last 12 months 2=More than 12 months

Note: If you don't know what the meaning of the word is, most likely you have not been diagnosed with it.

___ 001 Abscess___ 002 Acid R eflux

___ 003 Acne

___ 004 Addison's dis ease___ 005 Alcoholism

___ 006 Allergies___ 007 Allergy, C hemical___ 008 Alzheimers

___ 009 Amenorrhea___ 010 Anemia___ 011 Angina

___ 012 Anorexia___ 013 Anxiety___ 014 Appendicitis

___ 015 Arrhythmia___ 016 Arteriosclerosis___ 017 Arthritis

___ 018 Arthritis, infectious___ 019 Arthritis, juveni rheuma___ 020 Arthritis, osteo

___ 021 Arthritis, rheumatoid___ 022 Asthma___ 023 Athlete's F oot

___ 024 Attention def icit disord___ 025 Bacterial i nfections___ 026 Bed s ores

___ 027 Benign pr osthetichypertrophy

___ 028 Beriberi

___ 029 Bladder Inf ection(Cystitis)

___ 030 Boils

___ 031 Compulsive Eating___ 032 Bone dis orders/

deformities

___ 033 Bradycardia

___ 034 Bright's D isease___ 035 Bronchitis

___ 036 Bulimia___ 037 Bursitis___ 038 Calcium d eposits

/nodules___ 039 Cancer, b reast___ 040 Cancer, c olon

___ 041 Cancer, p rostrate___ 042 Cancer, s kin___ 043 Cancer, other ______

___ 044 Candidia___ 045 Carpal Tunnel Syndrome

___ 046 Chalmydia

___ 047 Chicken P ox___ 048 Chronic F atigue S yndr___ 049 Colitis

___ 050 Condylomas___ 051 Congestive l iver diseas___ 052 Conjunctivitis

___ 053 Crohn's D isease___ 054 Cytomeglaovirus___ 055 Deformities

___ 056 Depression___ 057 Dermatitis___ 058 Diabetes

___ 059 Diverticulitis___ 060 Diverticulosis___ 061 Drug abus e

___ 062 Duodenal Ulc er___ 063 Dysentery

___ 064 Dysmenorrhea___ 065 Dyspnea

___ 066 Dysuria

___ 067 Ear Inf ection___ 068 Eczema

___ 069 Emphysema___ 070 Endometriosis___ 071 Enuresis

___ 072 Epilepsy___ 073 Fibrocystic Breast

Disease

___ 074 Fibroids Ut erine___ 075 Fibromyalgia Syndr om___ 076 Food allergies

___ 077 Fungal Inf ections___ 078 Gall st ones___ 079 Gastritis

___ 080 German measl es(Rubella)

___ 081 Gingivitis

___ 082 Goiter___ 083 Gonorrhea___ 084 Gout

___ 085 Graves D isease___ 086 Hay f ever___ 087 Heart, enlarged

___ 088 Heart V alve pr oblems___ 089 Heel or bone spur___ 090 Hemorrhoids

___ 091 Hepatitis A___ 092 Hepatitis B___ 093 Hepatitis C

___ 094 Hernia___ 095 Herpes (F ever B listers)___ 096 Herpes, G enital

___ 097 Hiatal H ernia

___ 098 High Blood Pressure___ 099 High Cholest erol

___ 100 Hives___ 101 Hodgkin's Dis ease___ 102 Hyperactivity___ 103 Hyperadrenalism(high)

___ 104 Hypercalcemia (high)___ 105 Borderline diabetes

___ 106 Hyperpituitarism (high)___ 107 Hypersensitivity___ 108 Hyperthyroidism (high)

___ 109 Hypertrophy___ 110 Low Blood sugar___ 111 Hypopituitarism (low)

___ 112 Hypoproteinemia___ 113 Low Thyr oid___ 114 Impotence

___ 115 Indigestion (Dyspepsia)___ 116 Infertility___ 117 Influenza

___ 118 Insomnia___ 119 Irritable BowelSyndrom

___ 120 Jaundice

___ 121 Jock Itc h___ 122 Kawasaki S yndrome___ 123 Kidney dis ease

___ 124 Kidney, enlarged___ 125 Kidney st ones___ 126 Lactose intoler ance

___ 127 Learning Disabilit y___ 128 Leg ulc ers

___ 129 Lesions___ 130 Leukemia

___ 131 Liver, enlarged

___ 132 Low blood pressure___ 133 Lupus

___ 134 Malabsorption___ 135 Malnutrition___ 136 Manic D epression

___ 137 Measles___ 138 Melanoma___ 139 Memory pr oblems

___ 140 Meningitis___ 141 Menopause___ 142 Menstrual c ramps

___ 143 Migraine headache___ 144 Miscarriage___ 145 Moles

___ 146 Mononucleosis___ 147 Multiple Scl erosis___ 148 Mumps

___ 149 Muscular Dystrophy___ 150 Myocardial infarction___ 151 Nephritis(Kidney Infection)

___ 152 Nephrosis___ 153 Neuritis___ 154 Neurodermatitis

___ 155 Obesity___ 156 Osteoporosis___ 157 Paget's D isease o/Bone

___ 158 Palpitations___ 159 Pancreatitis___ 160 Panic attack

___ 161 Parkinson's Disease___ 162 Peptic ulc er___ 163 Pernicious A nemia

___ 164 Phobias

___ 165 Pituitary diseases/disorders

___ 166 PMS___ 167 Pneumonia___ 168 Polyps

___ 169 Prostate, enlarged___ 170 Psoriasis___ 171 Raynaud's D isease

___ 172 Reye's S yndrome___ 173 Rheumatic F ever___ 174 Ringworm

___ 175 Sciatica___ 176 Seizures___ 177 Shingles

___ 178 Sinusitis___ 179 Spleen, enl arged___ 180 Sterility

___ 181 Stroke___ 182 Tendonitis___ 183 Thrush

___ 184 Thyroid, enlarged___ 185 Thyrotoxicosis___ 186 Tonsilitis

___ 187 Tuberculosis___ 188 Tumors___ 189 Ulcers,others not listed

___ 190 Ulcerated C olitis___ 191 Uterine pr olapse___ 192 Vaginitis

___ 193 Valuvar c ardiacdisturbances

___ 194 Varicose V eins___ 195 Viral i nfections

___ 196 Whooping Cough

___ 197 Wilson's D isease___ 198 Yeast Inf ections

___ 199 Phlebitis___ 200 Thromboses___ 201 Venereal Dis ease

___ 202 Bell's P alsy___ 203 Scoliosis___ 204 Delirium

___ 205 Enteritis___ 206 Gastric ulcer___ 207 High bl ood sugar

___ 208 Hypertrophic arthritis___ 209 Multiple Pers onalities___ 210 Neuralgia

___ 211 Peritonitis___ 212 Polyneuritis___ 213 Sclerosis of the liver

___ 214 Spastic Colon___ 215 Hypoadrenalism___ 216 Varicose Ulc ers

___ 217 Fatty liver___ 218 Fibroid tu mors___ 219 Fluid in lungs

___ 220 Pupils dilated f requent

Other disorders/diseases, not

listed___ 221 auto-immune___ 222 blood/bleeding

___ 223 bowel___ 224 brain___ 225 circulatory

___ 226 digestive

___ 227 gland___ 228 cardiovascular

___ 229 connective tiss ue___ 230 jawbone___ 231 periodontal

___ 232 pancreatic___ 233 kidney___ 234 liver

___ 235 lung___ 236 nervous s ystem___ 237 muscle

___ 238 reproductive___ 239 skin___ 240 tic

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SECTION 2-Medications/Surgery

Check belowif you have ever had any of the following

surgically:

REMOVED

___ 001 appendix___ 002 fallopian tubes tied (tubal ligation)___ 003 gallbladder

___ 004 kidney___ 005 limbs___ 006 liver, partial removal of___ 007 lung___ 008 male testicles (castration)___ 009 prostate gland___ 010 spleen___ 011 thyroid___ 012 tonsils___ 013 uterus, ovaries (hysterectomy)___ 014 uterus (partial hysterectomy)___ 015 vas deferens (vasectomy

TRANSPLANTED

___ 016 heart pacemaker (implant)

___ 017 heart___ 018 kidney___ 019 limbs___ 020 liver___ 021 lung

Check the following for which you have used prescription

medications:

___ 031 antidiuretics ___ 061 chemical imbalances___ 032 adrenal ___ 062 chemotherapy, cancer___ 033 antifungal ___ 063 depression___ 034 arthritis ___ 064 diuretics___ 035 blood pressure ___ 065 food allergies/sensitivities

___ 036 cholesterol ___ 066 heart___ 037 cortisone ___ 067 hypothalamus___ 038 digestion ___ 068 hormones, estrogen therapy___ 039 emotional ___ 069 hormones, progesterone therapy___ 040 gallbladder ___ 070 hormones, testosterone therapy___ 041 hyperthyroid ___ 071 hyperactivity/attention deficit___ 042 hypothyroid ___ 072 male reproductive___ 043 impotence ___ 073 immune system, repression___ 044 inhalers ___ 074 joints, inflammation of___ 045 kidneys ___ 075 large intestine (colon)___ 046 liver ___ 076 pancreatic enzymes___ 047 lungs ___ 077 radioactive iodine treatment___ 048 lymph ___ 078 rheumatoid or inflammation___ 049 menopausal ___ 079 radiation, cancer___ 050 menstrual ___ 080 sleeping

___ 051 ovulation ___ 081 spleen___ 052 pineal ___ 082 upper respiratory___ 053 pituitary ___ 083 venereal disease___ 054 prostate___ 055 small intestine___ 056 stomach___ 057 urinary system___ 058 antibiotics (in the past year)___ 059 antiviral___ 060 birth control

SECTION 3-Pain/Swelling

Have you experienced pain or swelling in the following

areas?If answer is NO, go to the next question; otherwise,S= sometimes Y= yes

001 hips or buttock S Y002 fingers, swelling of S Y

003 elbows swollen S Y004 low back pain S Y005 throat/neck, swelling of S Y006 pain in left side under ribcage S Y007 pain in either side of back in fleshy or muscular part S Y008 left upper abdominal pain S Y009 pain in left side of abdomen S Y010 foot pain S Y011 low abdominal pain S Y012 neck pain S Y013 leg pain S Y014 pain in the region of the appendix S Y015 mid-back pain S Y016 pain around the naval S Y017 muscle pain S Y

018 painful spasms affecting bladder and urethra S Y019 swelling caused primarily by an excessive accumulation of

water in the body (Edema) S Y020 eyes, pain in S Y021 knee, painand swelling of (both) S Y022 intercourse, painful S Y023 pain in upper middle part of abdomen S Y024 pain in fingers S Y025 joint pain/aches S Y026 pain/cramps in arms, hands and feet (all three) S Y027 abdominal pain, generalized S Y028 anal pain S Y029 anal swelling S Y030 ankles, swelling of S Y031 pain in ankles S Y

032 upper right abdomen, pain in S Y033 pain in the upper middle region of the abdomen S Y034 back aches/pain, generalized S Y035 thigh, pains in S Y036 shoulders, pains in S Y037 big toe, painandswelling of (both) S Y038 severe abdominal pain radiating to back S Y039 body, pain in various parts of S Y040 bones sore/painful S Y041 chest pain S Y042 feet, swelling of S Y043 knees, swelling of S Y044 hands, swelling of S Y045 legs, swelling of S Y046 pain in the urinary bladder S Y

047 joint motion restricted by pain S Y

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___013 male characteristics severelyundeveloped/ diminished

___014 breast development significant___015 egg-shaped body___016 face hair is thick___017 pubic hair is thick

___018 sac over the testes is thick___019 slow to grow masculine hair___020 voice changed at age 12 to 13

SECTION 4-Female Only

FEMALE ONLY

Answer all questions; those that apply below. If answer is NO, go to the next question; otherwise, S= sometimes/somewhatY= yes

___001 height shorter than 5'___002 mustaches and beards, chest hair___003 breasts small (in proportion to body)___004 height more than 6'___005 large breasted (in proportion to body)

___006 currently pregnant___007 body covered with hair and/or heavy growth of hair in abnormal distribution___008 masculine features of the body___009 hoarseness and deepening of the voice___010 loss of female contours of the body___011 waist-hip measurement differential exceeds 10 inches012 menstruation, early & heavy S Y013 vaginal discharge S Y014 vaginal dryness &/or itching S Y015 menstruation has ceased S Y016 menstruation, less frequent S Y017 anxiety/irritability prior to or during period S Y018 blood clotting inmenses S Y019 violent prior to menstruation S Y020 burning/discomfort of vagina S Y

021 bleeding, irregular menstrual S Y022 severe/painful menstrual symptoms S Y023 skin eruptions prior to or during menstruation S Y024 menstruation late, more than 28 days between periods S Y025 cheesy discharge from the vagina S Y026 premenstrual periods, painful S Y027 burning & discomfort during intercourse S Y028 uterine cramping S Y029 a milky discharge from the breasts S Y030 personality/mood/emotional changes prior to or during menstruation S Y031 breast lumps S Y032 poor/ post-partum failure to lactate S Y033 breast tenderness S Y034 bleeding, heavy menstrual S Y

035 weight gain prior to menstruation S Y036 breast, candida infection of the nipples S Y037 rapid weight gain S Y038 breast swelling S Y039 inconsistent ovulation S Y

040 menstrual irregularities/problems S Y041 menstrual flow decreased/scanty S Y042 backache prior to menstruation S Y043 bleeding between menstrual cycles S Y044 cramps prior to menstruation S Y045 menstruation early, less than 28 days between periods S Y046 elevated body temperature S Y047 depression prior to menstruation S Y048 fainting spells prior to menstruation S Y049 fatigue prior to menstruation S Y050 feeling sick S Y051 food cravings prior to menstruation S Y052 insomnia prior to menstruation S Y053 joint pain prior to menstruation S Y054 low back ache during menstruation S Y055 mild to severe cramps usually in the lower abdomen

during menstruation S Y056 mild to severe headaches prior to menstruation S Y057 outbursts of anger prior to menstruation S Y058 pain in the breast prior to menstruation S Y059 pain running down the legs & thighs during menstruation S Y060 puffiness around the abdomen prior to menstruation S Y061 puffiness of the entire body prior to menstruation S Y062 retention of water prior to menstruation S Y063 slight or no rise in termperature at ovulat ion S Y064 thoughts of suicide prior to menstruation S Y065 menstrual periods cease prematurely S Y066 frequent spasms of the uterus or uterine area S Y

SECTION 5-Male Only

MALE ONLY

Answer all questions; those that apply below.

___001 very tall stature/more than 6'6" tall___002 a higher pitched voice___003 legs bowed___004 hair distribution is scanty___005 legs are longer than trunk

___006 well developed muscular structure___007 height shorter than 5'6"___008 strong masculine appearance___009 large distribution of masculine hair___010 large penis and testicles___011 late muscular development___012 acquiring some feminine characteristics

021 burning/painful urination S Y022 prostate infections/swel ling/pain S Y023 urgent urination S Y024 trousers becoming too tight in the hips S Y025 premature ejaculation S Y026 voluntarily stopped drinking coffee before

going to bed S Y027 personality changes S Y028 can't fully empty bladder S Y029 pain during ejaculation S Y030 pain in the testicles/prostate area S Y031 painful while sitting S Y032 sudden onset of sharp pain radiating from

the area between the testicle sac and anus S Y033 tendency to congestion of the prostate S Y

If answer is NO, go to the next question;otherwise, S= sometimes/somewhat

Y= es