Please print out this Patient Intake Form and bring it with
you to your session filled out

Name: _____________________________________________________Date_____________
                           
Address:_____________________________________________________________________

Phone:________________________________email:_________________________________

Date of Birth:__________________


Chief Complaint

What is your chief complaint?  When did it begin?  What aggravates it and what makes it
better?_______________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Past Medical History

Have you had any medical procedures/therapies/surgeries?
_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________



Are you taking medication/supplements/herbs?____________________________________

_____________________________________________________________________________



Body Temperature

Do you generally feel cold or hot?________________________________________________

Do you have fever/chills?_______________________________________________________

Skin

Do you have any skin conditions?________________________________________________
_
_____________________________________________________________________________

Digestion

How is your appetite?__________________________________________________________

Any weight gain/loss?__________________________________________________________

How is your digestion? Bloating, gas,  or cramps?__________________________________

_____________________________________________________________________________

_____________________________________________________________________________

How is your thirst?____________________________________________________________

Do you prefer hot/cold?_________________________________________________________

Do you have any food cravings?__________________________________________________

Elimination

Do you get constipated or have diarrhea?__________________________________________

How often do you have a bowel movement?________________________________________

Any undigested food, mucous or blood in your stool?________________________________

Urination

Is your urine scanty or profuse?__________________________________________________

Is the color of your urine clear, yellow, dark or cloudy?______________________________

Pain

Do you have headaches or dizziness?_____________________________________________

Do you have any pain in your body? Is it fixed or does it move around?

_____________________________________________________________________________

Is there soreness, numbness or heaviness?

_____________________________________________________________________________

Is it relieved or aggravated by pressure, movement, hot or cold?

_____________________________________________________________________________

Any specific time of day or night that it is better or worse?___________________________

Sleep

How many hours of sleep do you get?_____________________________________________

Do you sleep well? Do you have any trouble falling asleep and staying asleep?

_____________________________________________________________________________

Are you rested when you get out of bed? Do you feel fatigued through the day?

_____________________________________________________________________________

Do you have recurring dreams?

_____________________________________________________________________________

For Women:  Menstruation

Is your cycle the same amount of days each month? How long is it?

_____________________________________________________________________________

Is your flow heavy/light?________________________________________________________

What color is it?_______________________________________________________________

Do you have menstrual cramps? Are they before, during or after your menstrual flow?

____________________________________________________________________________

_____________________________________________________________________________

Do you have any clots?_________________________________________________________

Are you experiencing any menopausal symptoms? (Night sweats, insomnia, anxiety,
depression)
_____________________________________________________________________________

_____________________________________________________________________________

Do you have any vaginal discharge?  What is the consistency/color?

_____________________________________________________________________________


For Practitioner Use only

Tongue:______________________________________________________________________



Pulse:

Left:  ________________________________ Right:_________________________________

____________________________________________________________________________   
                                                     
_____________________________________________________________________________


Diagnosis:____________________________________________________________________


Treatment Principles:__________________________________________________________


Acupuncture Points:___________________________________________________________


Herbal Medicine:______________________________________________________________


Practitioner Signature:_____________________________________________________

Intake Form