Acupressure: User Friendly Self Healing


This form helps us determine how acupressure works for you.   Please describe as best you can your condition using this table. Each section is described below. If they don't seem to relate to your condition write any additional notes that would help clarify your situation. Follow-up forms will be sent to you during the next year to measure your results with acupressure so we can assist you if you are not getting the initial results you desire. Thank you for participating in our research. All information is confidential and used for research purposes only.

Problem: This term describes the type of problem you are having. This could be pain, depression, infection, fatigue, numbness, disease, or anything else that describes your condition.   Be specific like tension headache, cramping pain, pain from burns, etc.

Severity: Please use the following number scale to rank how severe your problem was during the last five days. Use any number between 0 to 10 (0 for none to 10 for unbearable). This number will be called severity. Enter it in the box below.                   

0          1        2         3        4        5         6         7        8         9       10
  l__ __l__ __l__ __l__ __l__ __l__ __l__ __l__ __l__ __l__ __l

0 None          2 Mild        4 Bad         6 Very Bad         8 Excruciating       10 Unbearable

Problem:(day 1)
Rank Severity of Problem today (0 for None, 10 for Unbearable or anywhere in between ):
Frequency: How often in the last five days did it bother you?
0 to 5
Number of pills you now take each day for this condition?


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Acu-Ki Institute Inc.   
PO Box 564

Snowflake, AZ. 85937
888-853-0646    monty@stress-away.com

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