Headaches/Tension	Irritability	Elbow Pain	Dizziness
Fatigue/Tired	Depression	Shoulder Pain	Allergies
Pain Anywhere in the Body	Anxiety	Hip Pain	Frequent Colds
Digestive Disturbance	Menstrual Problems	Pain Between Should Blades	Tension Across Shoulders
Constipation	Fertility Issues	Knee Pain	Numbness/Tingling in Arms or Hands
Urinary Problems	Low Back Pain	Ankle/Foot Pain	Numbness/Tingling in Legs or Feet
GERD/Heartburn	Neck Pain	Ringing in Ears	Weight Trouble
Difficulty Sleeping	Wrist/Hand Pain	Nervousness	Other:

Does this cause you to be:	Does this affect your work:	Does this affect your life:
Moody	Decision Making	Lose Patience with Spouse or Children
Depressed	Poor Attitude	Restricted Household Duties
Irritable	Decreased Productivity	Hinders Ability to Exercise or Participate in Sports
Sleeping with Interruptions	Exhausted at End of Day	Hinders Ability to Participate in Hobbies of Other Desired Activities
Restricted on Daily Activities	Unable to Work Long Hours

If you checked any of the above items, your organs are probably not functioning as well as they could, and your energy is probably not flowing as smoothly as it could be. ACUPUNCTURE AND CHINESE HERBAL MEDICINE CAN 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 check the most appropriate for you: I would like to come to East-West's office for an initial evaluation and consultation. There is NO CHARGE for this visit. This will allow me to find out if I can be helped by Acupuncture and Chinese Herbal Medicine without any financial barriers. I would like to come for further wellness classes.