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Make an appointment
- Please call our TCM acupunture clinic in Westmont to make an appointment with a practitioner.

Westmont office
Tel: 331-251-8180
Tel: 312-690-9666
665 Pasquinelli, Unit 203
Westmont, IL 60559
Driving Directions
Mon to Fri: 9:30am-5:30pm
Sat: 9:00am-4:00pm
Sun: By Appointment only

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 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 Westmont, 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:* (First time consultation fee:$120.00) 

Chicago Office    Westmont 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
 Nationality:*
 Address:*
 City:*  State:* Zip:*
 E-mail:*
 Phone(home):* -  Phone(work): -
 Occupation:
 How do you know us? *
1. Referred by friend: Friend's Name
2. Internet: Name of the search engine or website
3. Magazine or newspaper: Name
4. Other: Please specify
   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?
Family Medical History:
 
What other medication and/or supplements are you taking? And for how long?
 
 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:
 Diet: Any special diet?
Food cravings:   Sugar   Salt   Food allergies
  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   No
 Temperature:
  cold   hot   dampness   light
  noise   airborn
       particles		   food   durgs
  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:
 Eye, Ear, and Nose:   Normal   Abnormal
Describe:
 Sex Function:   Normal   Abnormal
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   No
 Menstrual Pain:         Yes   No
    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:
 Addictions:
Tobacco   Alcohol   Others
  Describe:
 Any other disorders or abnormalities:
  Describe:
     

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