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Diagnosis form

To best help you, I use this diagnosis form and (preferrably) a brief phone consult. Below is the diagnosis form that will help me to diagnose your illness properly. Should you have any problems filling out this form, please email me at alohadoc@gmail.com and I will attend your problem shortly. After completion and submital, feel free to call me at 808-896-0406 (9:00 am to 5:00 pm mountain standard time) Weekends are good.

BASIC PROFILE
What is your name?
What is your email address?
What is your occupation?
Your gender?
Your age?
Your measurement?	Height :Weight:
Chief concern or complaint:
History of problem: onset, previous diagnosis or treatment?
What makes it better or worse? Be as specific as possible about this...
Your parents past medical history: (Significant illnesses)	Cancer;Diabetes;High Blood Pressure;Hepatitis Rheumatic Fever;Thyroid Disease;Seizures
Your past medical history: Significant illnesses or surgeries	Cancer;Diabetes;High Blood Pressure;Hepatitis Rheumatic Fever;Thyroid Disease;Seizures Other significant trauma (auto accidents, falls, etc.);

DETAILED DIAGNOSIS FORM
PATTERNS OF DEPLETION DEFICIENT QI	weakness, lethargy or weariness;lowered libido;decreased motivation;dull thinking or feeling;poor appetite;weak digestion;susceptible to colds or flu;prolonged recovery following illness;pasty, pale complexion;limp hair;shortness of breath;aversion to talking;perspires easily with exertion;weak muscles;chills easily;infertility;frequent profuse urination;miscarriage;Sweat easily
SLACK QI	atony or prolapse of stomach, intestines, anus;fecal incontinence or constant diarrhea;hemroids;dizzy or weak after meal or bowel movement;loose or flaccid muscles
DEFICIENT MOISTURE	dry and thirsty;dryness of mucous membranes;scant secretions and urination;constipation;uncomfortable feeling of heat in the body;restlessness and insomnia;low fever in the afternoon or evening;parched and cracked skin;emotional lability;hot flashes;night sweats;constant hunger;unstable blood sugar;persistent dry cough;dry sore throat flushed face with dry skin and lips
SLACK MOISTURE	excess secretions from eyes, nose, mouth, skin, vagina (specify which);seminal incontinence or premature ejaculation;frequent urination, enuresis or incontinence;dizzy or weak after sex
DEFICIENT BLOOD	restless fatigue;irritability insomnia and anxious sleep;itching, prickling skin or scalp;dryness without thirst; blurred or weak vision;loss or thinning of hair;dizziness dry skin, eyes, hair;anemia;numbness of hands and feet;muscle cramps;lack of semen;scanty or irregular menstruation;pale, waxy, sallow complexion;easy bruising;poor skin healing;palpitations;postpartum weakness or anemia;emotionally sensitive
SLACK BL00D	bleeding from skin, nose, lungs,stomach, bladder, and intestines (specify);bleeding from skin, nose, lungs,stomach, bladder, and intestines (specify);excessive bleeding during menses, pregnancy or postpartum;bleeding hemorrhoids anemia associated with inflammation of stomach. small intestine or large intestine
DIMINISHED ESSENCE	generalized fatigue, weakness and stiffness;increased flaccidity of muscles sagging or wrinkling of skin diminished or absent sexual arousal and pleasurepremature infertility or menopause repeated miscarriagesloosening or increased loss of teeththinning, graying and drying of head and pubic hair weakening of bones and loss of elasticity of tendons or ligaments decline of memory, vision and hearing progressive lots of w eight or emaciation
DISTURBED SHEN	extreme restlessness, agitation or loquaciousness labile emotions (easily moved to tears or laughter) extreme hypersensitivity to pain or insult hysterical outbursts of shouting, laughing or grief overwhelming hopelessness. sadness or grief constant anxiety or incessant worry easily startled or frightened morbid thoughts or impulses erratic sleep, stubborn insomnia or disturbing dreams mental confusion and disorientation uncontrollable rage or elation incoherent speech or babbling dull, glazed or bizarre look to eyes and face
STAGNANT Ql	head feels stuffy mild nausea distention or fullness in chest or abdomen gas pains, cramps, tension in stomach or intestines hiccups,belching or flatulence constipation with gas vague or intermittent pains
OBSTRUCTED Ql	generalized discomfort, fullness, pressure in head, chest, limbs or abdomen belching or flatulence wheezing difficulty swallowing stitch or acute pain in abdomen sense of fullness under ribs
STAGNANT MOISTURE	soft or loose stool bloating with water retention puffy eyes, face, hands or ankles frequent but scanty urination feels swollen, tender, lethargic in humid weather soft swellings or enlarged lymph nodes premenstrual soreness and swelling of breasts
OBSTRUCTED MOISTURE	swollen or heavy head, limbs or abdomen tender muscles and joints thick or sticky saliva or phlegm sticky perspiration lumps, nodules and cysts sticky slimy stool
Any other things you would like to tell us?

Dr Bob Kelley

alohadoc@gmail.com

Phone (808) 896-0406