Intake Form

This information is essential for diagnosis and helps us to provide you with a better treatment. Please fill out the following questions as accurately as you can. All information on this form is confidential.

This form should be filled out and then printed. A completed Intake Form and signed Disclosure Form are needed on your first visit.

Date:

Name: Age:

Occupation:

Address:

. City: State: Zip: Telephone Home: Cell: Email: What do you want treated by acupuncture? How long have you had this condition? The onset was: Sudden Gradual What medical diagnosis have you received? What other treatments have you received recently for this and/or other conditions? What medications are you taking? For what condition(s)? List any vitamins and supplements you are taking. Are you always thirsty? Do you prefer hot or cold drinks? Do you have unusual sweating? How often do you urinate each day? Color: Pale yellow Dark yellow/orange How is your energy? Do you fatigue easily? What time of day is your energy: Highest Lowest How many hours do you normally sleep? What kind of exercise do you do? How often? Where do you hold stress? How do you relax? Do you have muscle pain or tightness? Where? The pain is (Check any that apply) Sharp Aching Numb Deep Pain Burning Dull Superficial Pain Tingling Pain worse/better with heat Pain worse/better with pressure Pain worse in AM PM Check any of the following that apply Belching Vomiting Vomiting of Blood Ulcers Nausea Bloating Acid regurgitations Heartburn Hernia Indigestion Severe stomach pain Other? Bowel movements- How often? Painful bowel movement Irregular Constipation Diarrhea Gas Burning Hemorrhoids Use laxatives Blood in stool Undigested food in stools Hard stool Loose stool Itchiness Other? Swollen joints Arthritis/joint pain Tendinitis Rheumatism Bone pain Muscle cramping Muscle pain Repetitive Strain Injury Other? Frequent colds Chronic runny nose Chronic Cough Pain inhaling Asthma Shortness of breath on exertion/rest Coughing blood Cough up mucous How much? Color of phlegm? Cold Sores Bleeding gums Nose bleeds Dry mouth Frequent sore throat Decreased sense of smell Ear pain Ringing in ears Clogged/popping ears Poor vision Pain/red eyes See spots Dizziness Frequent migraines/headaches Describe: High blood pressure Low blood pressure Diagnosed with heart trouble Chest pain Palpitations Phlebitis Varicose veins Cold hands & feet Irregular heart beat Poor circulation Other? Dry skin Skin rashes Itching Acne Eczema Hives Hair Loss Premature graying Panic attacks Depression Anxiety Bad Temper Nervousness Fear attacks Poor Memory Difficulty concentrating Problems falling asleep Problems staying asleep Disturbed sleep Nightmares Waking up at about AM / PM and not being able to fall asleep again because: Trouble starting stream when urinating Frequent Urination Incontinence Pain Dribbling with sneezing Burning Urinary Tract Infections Kidney stones Women (Please indicate current or previous menstruation conditions, even if now post menopausal) At what age did you start menstruating? Number of days between cycles Number of days of flow Color Describe your menstrual period, the days before, during and after. What is the flow like? Does the color change? Do you have pain? Irregular menstruation Heavy Flow Light Flow No Flow Clots Vaginal itching/burning Spotting between periods Discomfort/pain before period Discomfort/pain during period Tender Breasts with period Other? Any vaginal discharge? Amount: Color Frequency Blood or mucous discharge from breasts? PMS symptoms Menopausal symptoms Number of pregnancies Number of Deliveries Miscarriages/abortions Are you trying to get pregnant presently?

What sort of birth control do you use?

Men

I have (check any that apply)

Impotence Prostate problems Penis blood/mucous discharge Coldness or pain in the genital area

Other?

History

Family Medical History: (Please list any significant family illnesses) Mother Father Siblings Grandparents

Past Medical History: Have you had any of these? (check all that apply):

Lyme Disease Tuberculosis Herpes Rheumatic Fever Scarlet Fever Diabetes HIV

Hepatitis A, B or C

Describe any significant injuries, surgeries, or major illnesses, whether hospitalized or not, and the dates: