Dr. William G. von Peters, O.M.D., N.M.D., Ph.D.

Licensed in Acupuncture and Oriental Medicine

Professor – National Center for Preventive Medicine - Moscow
Visiting Professor – Heilongjiang University of Chinese Medicine
Rt.4, Box 93
Fairmont WV 26554
304-277-7104

—JMJ—

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:

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Signed: __________________________________________________________________ Date: ______________________

1
 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 ___ 064 Dysmenorrhea ___ 129 Lesions ___ 194 Varicose Veins
___ 002 Acid Reflux ___ 065 Dyspnea ___ 130 Leukemia ___ 195 Viral infections
___ 003 Acne ___ 066 Dysuria ___ 131 Liver, enlarged ___ 196 Whooping Cough
___ 004 Addison's disease ___ 067 Ear Infection ___ 132 Low blood pressure ___ 197 Wilson's Disease
___ 005 Alcoholism ___ 068 Eczema ___ 133 Lupus ___ 198 Yeast Infections
___ 006 Allergies ___ 069 Emphysema ___ 134 Malabsorption ___ 199 Phlebitis
___ 007 Allergy, Chemical ___ 070 Endometriosis ___ 135 Malnutrition ___ 200 Thromboses
___ 008 Alzheimer’s ___ 071 Enuresis ___ 136 Manic Depression ___ 201 Venereal Disease
___ 009 Amenorrhea ___ 072 Epilepsy ___ 137 Measles ___ 202 Bell's Palsy
___ 010 Anemia ___ 073 Fibrocystic Breast ___ 138 Melanoma ___ 203 Scoliosis
___ 011 Angina Disease ___ 139 Memory problems ___ 204 Delirium
___ 012 Anorexia ___ 074 Fibroids Uterine ___ 140 Meningitis ___ 205 Enteritis
___ 013 Anxiety ___ 075 Fibromyalgia Syndrom ___ 141 Menopause ___ 206 Gastric ulcer
___ 014 Appendicitis ___ 076 Food allergies ___ 142 Menstrual cramps ___ 207 High blood sugar
___ 015 Arrhythmia ___ 077 Fungal Infections ___ 143 Migraine headache ___ 208 Hypertrophic arthritis
___ 016 Arteriosclerosis ___ 078 Gall stones ___ 144 Miscarriage ___ 209 Multiple Personalities
___ 017 Arthritis ___ 079 Gastritis ___ 145 Moles ___ 210 Neuralgia
___ 018 Arthritis, infectious ___ 080 German measles ___ 146 Mononucleosis ___ 211 Peritonitis
___ 019 Arthritis, juveni rheuma (Rubella) ___ 147 Multiple Sclerosis ___ 212 Polyneuritis
___ 020 Arthritis, osteo ___ 081 Gingivitis ___ 148 Mumps ___ 213 Sclerosis of the liver
___ 021 Arthritis, rheumatoid ___ 082 Goiter ___ 149 Muscular Dystrophy ___ 214 Spastic Colon
___ 022 Asthma ___ 083 Gonorrhea ___ 150 Myocardial infarction ___ 215 Hypoadrenalism
___ 023 Athlete's Foot ___ 084 Gout ___ 151 Nephritis (Kidney Infection) ___ 216 Varicose Ulcers
___ 024 Attention deficit disord ___ 085 Graves’ Disease ___ 152 Nephrosis ___ 217 Fatty liver
___ 025 Bacterial infections ___ 086 Hay fever ___ 153 Neuritis ___ 218 Fibroid tumors
___ 026 Bed sores ___ 087 Heart, enlarged ___ 154 Neurodermatitis ___ 219 Fluid in lungs
___ 027 Benign prosthetic ___ 088 Heart Valve problems ___ 155 Obesity ___ 220 Pupils dilated frequent
hypertrophy ___ 089 Heel or bone spur ___ 156 Osteoporosis
___ 028 Beriberi ___ 090 Hemorrhoids ___ 157 Paget's Disease o/Bone Other disorders/diseases, not
___ 029 Bladder Infection ___ 091 Hepatitis A ___ 158 Palpitations listed
(Cystitis) ___ 092 Hepatitis B ___ 159 Pancreatitis ___ 221 auto-immune
___ 030 Boils ___ 093 Hepatitis C ___ 160 Panic attack ___ 222 blood/bleeding
___ 031 Compulsive Eating ___ 094 Hernia ___ 161 Parkinson's Disease ___ 223 bowel
___ 032 Bone disorders/ ___ 095 Herpes (Fever Blisters) ___ 162 Peptic ulcer ___ 224 brain
deformities ___ 096 Herpes, Genital ___ 163 Pernicious Anemia ___ 225 circulatory
___ 033 Bradycardia ___ 097 Hiatal Hernia ___ 164 Phobias ___ 226 digestive
___ 034 Bright's Disease ___ 098 High Blood Pressure ___ 165 Pituitary diseases ___ 227 gland
___ 035 Bronchitis ___ 099 High Cholesterol /disorders ___ 228 cardiovascular
___ 036 Bulimia ___ 100 Hives ___ 166 PMS ___ 229 connective tissue
___ 037 Bursitis ___ 101 Hodgkin's Disease ___ 167 Pneumonia ___ 230 jawbone
___ 038 Calcium deposits ___ 102 Hyperactivity ___ 168 Polyps ___ 231 periodontal
/nodules ___ 103 Hyperadrenalism (high) ___ 169 Prostate, enlarged ___ 232 pancreatic
___ 039 Cancer, breast ___ 104 Hypercalcemia (high) ___ 170 Psoriasis ___ 233 kidney
___ 040 Cancer, colon ___ 105 Borderline diabetes ___ 171 Raynaud's Disease ___ 234 liver
___ 041 Cancer, prostrate ___ 106 Hyperpituitarism (high) ___ 172 Reye's Syndrome ___ 235 lung
___ 042 Cancer, skin ___ 107 Hypersensitivity ___ 173 Rheumatic Fever ___ 236 nervous system
___ 043 Cancer, other ______ ___ 108 Hyperthyroidism (high) ___ 174 Ringworm ___ 237 muscle
___ 044 Candidia ___ 109 Hypertrophy ___ 175 Sciatica ___ 238 reproductive
___ 045 Carpal Tunnel Syndrome ___ 110 Low Blood sugar ___ 176 Seizures ___ 239 skin
___ 046 Chalmydia ___ 111 Hypopituitarism (low) ___ 177 Shingles ___ 240 tic
___ 047 Chicken Pox ___ 112 Hypoproteinemia ___ 178 Sinusitis
___ 048 Chronic Fatigue Syndr ___ 113 Low Thyroid ___ 179 Spleen, enlarged
___ 049 Colitis ___ 114 Impotence ___ 180 Sterility
___ 050 Condylomas ___ 115 Indigestion (Dyspepsia) ___ 181 Stroke
___ 051 Congestive liver diseas ___ 116 Infertility ___ 182 Tendonitis
___ 052 Conjunctivitis ___ 117 Influenza ___ 183 Thrush
___ 053 Crohn's Disease ___ 118 Insomnia ___ 184 Thyroid, enlarged
___ 054 Cytomeglaovirus ___ 119 Irritable Bowel Syndrom ___ 185 Thyrotoxicosis
___ 055 Deformities ___ 120 Jaundice ___ 186 Tonsilitis
___ 056 Depression ___ 121 Jock Itch ___ 187 Tuberculosis
___ 057 Dermatitis ___ 122 Kawasaki Syndrome ___ 188 Tumors
___ 058 Diabetes ___ 123 Kidney disease ___ 189 Ulcers, others not listed
___ 059 Diverticulitis ___ 124 Kidney, enlarged ___ 190 Ulcerated Colitis
___ 060 Diverticulosis ___ 125 Kidney stones ___ 191 Uterine prolapse
___ 061 Drug abuse ___ 126 Lactose intolerance ___ 192 Vaginitis
___ 062 Duodenal Ulcer ___ 127 Learning Disability ___ 193 Valuvar cardiac
___ 063 Dysentery ___ 128 Leg ulcers disturbances

2
 SECTION 2-Medications/Surgery SECTION 3-Pain/Swelling
Check below if you have ever had any of the following Have you experienced pain or swelling in the following
surgically: areas?
If answer is NO, go to the next question; otherwise,
REMOVED S= sometimes Y= yes
___ 001 appendix
___ 002 fallopian tubes tied (tubal ligation) 001 hips or buttock S Y
___ 003 gallbladder 002 fingers, swelling of S Y
___ 004 kidney 003 elbows swollen S Y
___ 005 limbs 004 low back pain S Y
___ 006 liver, partial removal of 005 throat/neck, swelling of S Y
___ 007 lung 006 pain in left side under ribcage S Y
___ 008 male testicles (castration) 007 pain in either side of back in fleshy or muscular part S Y
___ 009 prostate gland 008 left upper abdominal pain S Y
___ 010 spleen 009 pain in left side of abdomen S Y
___ 011 thyroid 010 foot pain S Y
___ 012 tonsils 011 low abdominal pain S Y
___ 013 uterus, ovaries (hysterectomy) 012 neck pain S Y
___ 014 uterus (partial hysterectomy) 013 leg pain S Y
___ 015 vas deferens (vasectomy 014 pain in the region of the appendix S Y
015 mid-back pain S Y
TRANSPLANTED 016 pain around the naval S Y
___ 016 heart pacemaker (implant) 017 muscle pain S Y
___ 017 heart 018 painful spasms affecting bladder and urethra S Y
___ 018 kidney 019 swelling caused primarily by an excessive accumulation of
___ 019 limbs water in the body (Edema) S Y
___ 020 liver 020 eyes, pain in S Y
___ 021 lung 021 knee, pain and swelling of (both) S Y
022 intercourse, painful S Y
Check the following for which you have used prescription 023 pain in upper middle part of abdomen S Y
medications: 024 pain in fingers S Y
025 joint pain/aches S Y
026 pain/cramps in arms, hands and feet (all three) S Y
___ 031 antidiuretics ___ 061 chemical imbalances 027 abdominal pain, generalized S Y
___ 032 adrenal ___ 062 chemotherapy, cancer 028 anal pain S Y
___ 033 antifungal ___ 063 depression 029 anal swelling S Y
___ 034 arthritis ___ 064 diuretics 030 ankles, swelling of S Y
___ 035 blood pressure ___ 065 food allergies/sensitivities 031 pain in ankles S Y
___ 036 cholesterol ___ 066 heart 032 upper right abdomen, pain in S Y
___ 037 cortisone ___ 067 hypothalamus 033 pain in the upper middle region of the abdomen S Y
___ 038 digestion ___ 068 hormones, estrogen therapy 034 back aches/pain, generalized S Y
___ 039 emotional ___ 069 hormones, progesterone therapy 035 thigh, pains in S Y
___ 040 gallbladder ___ 070 hormones, testosterone therapy 036 shoulders, pains in S Y
___ 041 hyperthyroid ___ 071 hyperactivity/attention deficit 037 big toe, pain and swelling of (both) S Y
___ 042 hypothyroid ___ 072 male reproductive 038 severe abdominal pain radiating to back S Y
___ 043 impotence ___ 073 immune system, repression 039 body, pain in various parts of S Y
___ 044 inhalers ___ 074 joints, inflammation of 040 bones sore/painful S Y
___ 045 kidneys ___ 075 large intestine (colon) 041 chest pain S Y
___ 046 liver ___ 076 pancreatic enzymes 042 feet, swelling of S Y
___ 047 lungs ___ 077 radioactive iodine treatment 043 knees, swelling of S Y
___ 048 lymph ___ 078 rheumatoid or inflammation 044 hands, swelling of S Y
___ 049 menopausal ___ 079 radiation, cancer 045 legs, swelling of S Y
___ 050 menstrual ___ 080 sleeping 046 pain in the urinary bladder S Y
___ 051 ovulation ___ 081 spleen 047 joint motion restricted by pain S Y
___ 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

3
 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/somewhat
Y= yes
___001 height shorter than 5' 035 weight gain prior to menstruation S Y
___002 mustaches and beards, chest hair 036 breast, candida infection of the nipples S Y
___003 breasts small (in proportion to body) 037 rapid weight gain S Y
___004 height more than 6' 038 breast swelling S Y
___005 large breasted (in proportion to body) 039 inconsistent ovulation S Y
___006 currently pregnant 040 menstrual irregularities/problems S Y
___007 body covered with hair and/or heavy growth of hair in abnormal distribution 041 menstrual flow decreased/scanty S Y
___008 masculine features of the body 042 backache prior to menstruation S Y
___009 hoarseness and deepening of the voice 043 bleeding between menstrual cycles S Y
___010 loss of female contours of the body 044 cramps prior to menstruation S Y
___011 waist-hip measurement differential exceeds 10 inches 045 menstruation early, less than 28 days between periods S Y
012 menstruation, early & heavy S Y 046 elevated body temperature S Y
013 vaginal discharge S Y 047 depression prior to menstruation S Y
014 vaginal dryness &/or itching S Y 048 fainting spells prior to menstruation S Y
015 menstruation has ceased S Y 049 fatigue prior to menstruation S Y
016 menstruation, less frequent S Y 050 feeling sick S Y
017 anxiety/irritability prior to or during period S Y 051 food cravings prior to menstruation S Y
018 blood clotting inmenses S Y 052 insomnia prior to menstruation S Y
019 violent prior to menstruation S Y 053 joint pain prior to menstruation S Y
020 burning/discomfort of vagina S Y 054 low back ache during menstruation S Y
021 bleeding, irregular menstrual S Y 055 mild to severe cramps usually in the lower abdomen
022 severe/painful menstrual symptoms S Y during menstruation S Y
023 skin eruptions prior to or during menstruation S Y 056 mild to severe headaches prior to menstruation S Y
024 menstruation late, more than 28 days between periods S Y 057 outbursts of anger prior to menstruation S Y
025 cheesy discharge from the vagina S Y 058 pain in the breast prior to menstruation S Y
026 premenstrual periods, painful S Y 059 pain running down the legs & thighs during menstruation S Y
027 burning & discomfort during intercourse S Y 060 puffiness around the abdomen prior to menstruation S Y
028 uterine cramping S Y 061 puffiness of the entire body prior to menstruation S Y
029 a milky discharge from the breasts S Y 062 retention of water prior to menstruation S Y
030 personality/mood/emotional changes prior to or during menstruation S Y 063 slight or no rise in termperature at ovulation S Y
031 breast lumps S Y 064 thoughts of suicide prior to menstruation S Y
032 poor/ post-partum failure to lactate S Y 065 menstrual periods cease prematurely S Y
033 breast tenderness S Y 066 frequent spasms of the uterus or uterine area S Y
034 bleeding, heavy menstrual S Y

SECTION 5-Male Only

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

___001 very tall stature/more than 6'6" tall ___013 male characteristics severely 021 burning/painful urination S Y
___002 a higher pitched voice undeveloped/ diminished 022 prostate infections/swelling/pain S Y
___003 legs bowed ___014 breast development significant 023 urgent urination S Y
___004 hair distribution is scanty ___015 egg-shaped body 024 trousers becoming too tight in the hips S Y
___005 legs are longer than trunk ___016 face hair is thick 025 premature ejaculation S Y
___006 well developed muscular structure ___017 pubic hair is thick 026 voluntarily stopped drinking coffee before
___007 height shorter than 5'6" going to bed S Y
___008 strong masculine appearance ___018 sac over the testes is thick 027 personality changes S Y
___009 large distribution of masculine hair ___019 slow to grow masculine hair 028 can't fully empty bladder S Y
___010 large penis and testicles ___020 voice changed at age 12 to 13 029 pain during ejaculation S Y
___011 late muscular development 030 pain in the testicles/prostate area S Y
___012 acquiring some feminine characteristics 031 painful while sitting S Y
032 sudden onset of sharp pain radiating from
the area between the testicle sac and anus S Y
033 tendency to congestion of the prostate S Y