Patient Intake Form

Thank you for filling out this form that helps us to serve your health care needs.

Part I: Personal Information

E-mail (required)

Gender Male Female (required)

Past occupations

(leave blank if none)

Marital status

Married
Single
Divorced

Number of children Ages (leave blank if none)

How many miscarriages? (leave blank if none)

How many abortions? (leave blank if none)

Part II: General

Do you have silver (amalgam) fillings?

Have you had a root canal?

Please list any medications (natural supplements) you currently take, for what conditions, and how long you've taken them.

(leave blank if none)

Please list any known allergies

(leave blank if none)

Other treatments or health care providers tried in the past

(leave blank if none)

Type of water that you drink Tap Spring Distilled Reverse Osmosis Well Water Other

Please list the 5 major health concerns in your order of importance:

Psycho/Social

Depression

Tension

Attempted suicide

Easily angered/easy to cry

Mood swings

Phobias

Anxiety/Nervousness

Sleep problems

Have you ever had psychiatric-psychological counselling?

How content are you with your life?(1-10; 10, very content) 1 2 3 4 5 6 7 8 9 10

Do you express emotions easily?

What would you like to change in your life?

What are the major stresses in your life?

Cardiovascular

Heart disease

Chest pain/angina

Stroke

Phlebitis

Ankle swelling

High blood pressure

Palpitations/Irregular heart beat

Murmurs

Rheumatic fever

Other

Respiratory

Chronic or frequent cough

Difficulty breathing

Frequent colds

Wheezing - How many times per year do you have wheezing?

Asthma

Chronic mucous in throat

Hayfever

Pain on breathing

Shortness of breath

Bronchitis

Emphysema

Chest pain

Pneumonia

Coughing blood

Pleurisy

Other

Part III: Conditions

Please select the appropriate number, 1,2, or 3 on the questions below

(1= occasionally, 2= often, 3 = always or nearly always)

Please ONLY mark the issues that apply to you. Leave the others BLANK.

Category I:Colon (leave blank if none)

1 2 3 Feeling that bowels do not empty completely

1 2 3 Lower abdominal pain, relieved by passing stool or gas

1 2 3 Alternating constipation and diarrhea

1 2 3 Diarrhea

1 2 3 Constipation

1 2 3 Hard, dry, or small stool

1 2 3 Coated tongue or "fuzzy " debris on tongue

1 2 3 Pass large amount of foul smelling gas

1 2 3 More than 3 bowel movements daily

1 2 3 Do you use laxatives frequently

Category II: Hypochlorydia (leave blank if none)

1 2 3 Excessive belching, burping, or bloating

1 2 3 Gas immediately following a meal

1 2 3 Offensive breath

1 2 3 Difficult bowel movements

1 2 3 Sense of fullness during and after meals

1 2 3 Difficulty digesting fruits and vegetables; undigested foods found in stools

Category III: Hyperacidity (Ulcer) (leave blank if none)

1 2 3 Stomach pain, burning or aching I-4 hours after eating

1 2 3 Do you frequently use antacids

1 2 3 Feeling hungry an hour or two after eating

1 2 3 Heartburn when lying down or bending forward

1 2 3 Temporary relief from antacids, food, milk, carbonated beverages

1 2 3 Digestive problems subside with rest and relaxation

1 2 3 Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

Category IV: Small Intestine (pancreas) (leave blank if none)

1 2 3 Roughage and fiber cause constipation

1 2 3 Indigestion and fullness lasts 2-4 hours after eating

1 2 3 Pain, tenderness, soreness on left side under rib cage bloated

1 2 3 Excessive passage of gas

1 2 3 Nausea and/or vomiting

1 2 3 Stool undigested, foul smelling, mucous-like, greasy, or poorly formed

1 2 3 Frequent urination

1 2 3 Increased thirst and appetite

1 2 3 Difficulty losing weight

Category V: Biliary Insufficiency/Statis (leave blank if none)

1 2 3 Greasy or high fat foods cause distress

1 2 3 Lower bowel gas and or bloating several hours after eating

1 2 3 Bitter metallic taste in mouth, especially in the morning

1 2 3 Unexplained itchy skin

1 2 3 Yellowish cast to eyes

1 2 3 Stool color alternates from clay colored to normal brown

1 2 3 Reddened skin, especially palms

1 2 3 Dry or flaky skin and/or hair

1 2 3 History of gallbladder attacks or stones

Have you had your gallbladder removed?

Category VI: Hypoglycemia (leave blank if none)

1 2 3 Crave sweets during the day

1 2 3 Irritable if meals are missed

1 2 3 Depend of coffee to get started or keep yourself going

1 2 3 Get lightheaded if meals are missed

1 2 3 Eating relieves fatigue

1 2 3 Feel shaky, jittery, tremors

1 2 3 Agitated, easily upset, nervous

1 2 3 Poor memory, forgetful

1 2 3 Blurred vision

Category VII: Insulin Resistance (leave blank if none)

1 2 3 Fatigue after meals

1 2 3 Crave sweets during the day

1 2 3 Eating sweets does not relieve cravings for sugar

1 2 3 Must have sweets after meals

1 2 3 Waist girth is equal or larger than hip girth

1 2 3 Frequent urination

1 2 3 Increased thirst and appetite

1 2 3 Difficulty losing weight

Category VIII: Adrenal Hypofunction (leave blank if none)

1 2 3 Cannot stay asleep

1 2 3 Crave salt

1 2 3 Slow starter in the morning

1 2 3 Afternoon fatigue

1 2 3 Dizziness when standing up quickly

1 2 3 Afternoon headaches

1 2 3 Headaches with exertion or stress

1 2 3 Weak nails

Category IX: Adrenal Hyperfunction (leave blank if none)

1 2 3 Cannot fall asleep

1 2 3 Perspire easily

1 2 3 Under high amounts of stress

1 2 3 Weight gain when under stress

1 2 3 Wake up tired even after 6 or more hours of sleep

1 2 3 Excessive perspiration or perspiration with little or no activity

Category X: Hypothyroid (leave blank if none)

1 2 3 Tired, sluggish

1 2 3 Feel cold - hands, feet, all over

1 2 3 Require excessive amounts of sleep to function properly

1 2 3 Increase in weight gain even with low-calorie diet

1 2 3 Gain weight easily

1 2 3 Difficult, infrequent bowel movements

1 2 3 Depression, lack of motivation

1 2 3 Morning headaches that wear off as the day progresses

1 2 3 Outer third of eyebrow thins

1 2 3 Thinning of hair on scalp, face or genitals or excessive falling hair

1 2 3 Dryness of skin and/or scalp

1 2 3 Mental sluggishness

Category XI: Thyroid Hyperfunction (leave blank if none)

1 2 3 Heart palpations

1 2 3 Inward trembling

1 2 3 Increased pulse even at rest

1 2 3 Nervous and emotional

1 2 3 Insomnia

1 2 3 Night sweats

1 2 3 Difficulty gaining weight

Category XU: Pituitary Hypofunction (leave blank if none)

1 2 3 Diminished sex drive

1 2 3 Menstrual disorders or lack of menstruation

1 2 3 Increased ability to eat sugars without symptoms

Category XDI: Pituitary Hyperfunction (leave blank if none)

1 2 3 Increased sex drive

1 2 3 Tolerance to sugars reduced

1 2 3 Splitting type headaches

Category XIV (Male Only): Prostate (leave blank if none)

1 2 3 Urination difficulty or dribbling

1 2 3 Urination frequent

1 2 3 Pain inside of legs or heels

1 2 3 Feeling of incomplete bowel evacuation

1 2 3 Leg nervousness at night

Category XV (Males Only): Andropause (leave blank if none)

1 2 3 Decrease in libido

1 2 3 Decrease in spontaneous morning erections

1 2 3 Decrease in fullness of erections

1 2 3 Difficulty in maintain morning erections

1 2 3 Spells of mental fatigue

1 2 3 Inability to concentrate

1 2 3 Episodes of depression

1 2 3 Muscle soreness

1 2 3 Decrease in physical stamina

1 2 3 Unexplained weight gain

1 2 3 Increase in fat distribution around chest and hips

1 2 3 Sweating attacks

1 2 3 More emotional than in the-past

Category XVI (Menstruating Females Only) (leave blank if none)

1 2 3 Are you perimenopausal

1 2 3 Alternating menstrual cycle lengths

1 2 3 Extended menstrual cycle, greater than 32 days

1 2 3 Shortened menses - less than every 24 days

1 2 3 Pain and cramping during periods

1 2 3 Scanty blood flow

1 2 3 Heavy blood flow

1 2 3 Breast pain and swelling during menses

1 2 3 Pelvic pain during menses

1 2 3 Irritable and depressed during menses

1 2 3 Acne break outs

1 2 3 Facial hair growth

1 2 3 Hair loss/thinning

Category XVII (Menopausal Females Only) (leave blank if none)

How many years have you been menopausal?

Do you ever have uterine bleeding since menopause?

1 2 3 Hot flashes

1 2 3 Mental fogginess

1 2 3 Disinterest in sex

1 2 3 Mood swings

1 2 3 Depression

1 2 3 Painful intercourse

1 2 3 Shrinking breasts

1 2 3 Facial hair growth

1 2 3 Acne

1 2 3 Increased vaginal pain, dryness or itching

Part IV: Foods

How many alcoholic beverages do you consume per week? What Kind? Beer Wine Liquer Combination

How many caffeinated beverages do you consume per day? What Kind? Coffee Tea Pop Combination with artificial sweeteners?

How many times do you eat out per week?

How many times a week do you eat raw nuts or seeds?

How many times a week do you eat fish?

How many times a week do you workout?

List the three worst foods you eat during the average week?

List the three healthiest foods you eat during the average week?

Do you smoke? If yes, how many times a day a week

Rate your stress levels on a scale of 1-10 during the average week.

Part V: Family History (leave blank if none)

Please check which diseases apply to any blood relative (Mother, father, sister, brother, grandmother, grandfather, others - who?)

Please list in order of appearance from your birth, all hospitalizations, surgeries, diseases, major accidents, traumas and scars (emotional and physical). (leave blank if none)

Age

Age

Age

Age

Age

Age

Age

Is there anything else that you feel I should know about you?

(leave blank if none)

Note: Some insurance companies will cover certain types of alternative healing. You may want to call your insurance company before your appointment to ask if they cover the services of an acupuncturist. Please let us know if you intend to submit a claim so we can code your invoice accordingly.

Yes, I plan to submit
No coverage at this time