Patient Intake Form

eMail:
First Name: Last Name:
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Emergency Contact:
Birth Date: Occupation: Marital Status:
Age: Height: Weight (lbs.): Gender:
Referred by:
Reason for visit today:      Today's Date:

Have you had acupuncture before before? Yes No
Chinese or Ayurvedic herbal medicine?
Yes No

How long have you had this condition?
Is it getting worse?Yes No
Does it bother your:SleepWork
Other (please list:)
 What seemed to be the initial cause?
What seems to make it better?
 What seems to make it worse?

Are you under the care of a physician now?Yes No
If yes, for what?
Who is your physician? Physician's Phone:
Other concurrent therapies:

Health Insurance Information
Insurance Co. Name: Policy # :
Address:
City: State:Zip Code:
Phone:

Medicare Information
Insurance Co. Name: Policy # :
Address:
City: State:Zip Code:
Phone:

Family Medical History (check all that apply)

Arteriosclerosis
Asthma
Alcoholism		 Diabetes
Heart Disease
High Blood Pressure		 Seizures
Stroke
Allergies
 Cancer

Your Past Medical History

Check any of the following conditions you currently have, or have had in the past.
Please also check if you feel any of the following are a significant part of your medical history.
AIDS/HIV
Alcoholism
Allergies
Appendicitis
Arteriosclerosis
Asthma
Birth Trauma
Cancer
ChickenPox
Diabetes		 Emphy Sema
Epilepsy
Goiter
Gout
Heart Disease
Hepatitus
Herpes
High Blood Pressure
Measles
Mumps		 Multiple Sclerosis
Pacemaker
Pleurisy
Pneumonia
Polio
Rheumatic Fever
Scarlet Fever
Seizures
Stroke
Surgery
 Tuberculosis
Typhoid Fever
Ulcers
Venereal Disease
Thyroid Disorders
Whooping Cough
Major Trauma
Other

Your Diet

Appetite:High Low
Does your diet include substantial amounts of the following:
Coffee soft Drinks Artificial Sweetner Sugar Salty Food
Thirst for Water (# glasses per day):
Average Daily Menu
Morning
    Snack   
Noon
    Snack   
Evening
    Snack   
Vitamins/supplements taken in last 2 months:
Pharmaceuticals taken in last 2 months:

Your Lifestyle

Check all that apply (confidentiality is ensured):
Alcohol
Tobacco		 Marijuana
Drugs		 Stress
Occupational Hazards		 Regular Exercise:

General Symptoms

Poor appetite
Heavy appetite
Strongly like cold drinks
Strongly like hot drinks
Recent weight loss/gain
Poor sleep
Heavy sleep
Dream-disturbed sleep
Fatigue
 Lack of strength
Bodily heaviness
Cold hands or feet
Poor circulation
Shortness of breath
Fever
Chills
Night sweats
 Sweat easily
Muscle cramps
Vertigo or dizziness
Bleed or bruise easily
Peculiar taste:

Head, Eyes, Ears, Nose, Throat

Glasses
Eye strain
Eye pain
Red eyes
Itchy eyes
Spots in eyes
Poor vision
Blurred vision
Night blindness
Glaucoma
Cataracts
Teeth problems
 Grinding teeth
TMJ
Facial pain
Gum problems
Sores on lips/tongue
Swollen glands
Dry mouth
Excessive saliva
Sinus problems
Recurrent sore throat
Lumps in throat
Enlarged thyroid
 Headaches
Migraines
Concussions
Nose bleeds
Poor hearing
Earaches
Ringing in ears
Excessive phlegm
Color of phlegm:
Other head or neck problems:  

Respiratory

Tight chest
Asthma/wheezing		 Pneumonia
Coughing blood		 Shortness of breath
Difficulty breathing when lying down
Cough: Wet or Dry?  Thick or Thin? 

Cardiovascular

High blood pressure
Low blood pressure
 Chest pain
Phlebitis
 Blood clots
Tachyeardia
 Difficulty breathing
Heart palpitations		 Irregular heartbeat
Fainting

Gastrointestinal

Intestinal pain or cramping
Nausea
Diarrhea
Vomiting
Constipation
Laxative use
Itchy anus		 Rectal pain
Burning anus
Hemorrhoid
Bloody stools
Black stools
Mucous in stools
Anal fissures		 Bad breath
Hiccup
Acid regurgitation
Gas
Bloating
Bowel movements:
Frequency (times/day): Texture/form:
Color: Odor:

Musculoskeletal

Neck/shoulder pain
Joint pain		 Upper back pain
Low back pain		 Muscle pain
Rib pain		 Limited range of motion
Limited use		 Other:

Skin and Hair

Rashes
Hives
Itching		 Eczema
Psoriasis
Ulcerations		 Fungal infections
Acne
Dandruff		 Change in hair/skin texture
Hair loss		 Other:

Neuropsychological

Seizures
Numbness
Tics		 Poor memory
Depression
Anxiety		 Irritability
Easily stressed
Abuse survivor		 Considered/Attempted suicide
Seeing a therapist
 Other:

Genito-urinary

Pain on urination
Frequent urination
Urgent urination		 Unable to hold urine
Bedwetting
Wake to urinate		 Incomplete urination
Blood in urine
Kidney stone		 Premature ejaculation
Nocturnal emission
Impotence		 Decreased libido
Increased libido
Venereal disease

Gynecology

Irregular periods
Vaginal discharge		 Vaginal sores
Vaginal odor		 Painful periods
Breast lumps		 Clots
PMS
Age menses began:  years Length of cycle (day 1 to day 1): Duration of flow:
Date of last PAP: Date last period began: Age at Menopause:
# Pregnancies: # Live births: # Premature births :

Other: