Sage Earth Acupuncture New Client Intake Form Dayna Meier R. Ac. TCMD First Name: Last Name: Today’s Date: Address: City/Province: Postal Code: Telephone (home): Telephone (work): Email: Date of Birth: Primary reasons for your visit: Health concerns: Current Medications: Current Supplements (Vitamins, Supplements, Herbal medicine, Homeopathy): Health History: List Injuries, Surgeries, Hospitalization, Major Illnesses Allergies: q Food qEnvironment q Seasonal q Chemical q Medication Please list specific allergies: Sage Earth Acupuncture New Client Intake Form Dayna Meier R. Ac. TCMD Health Checklist: check symptoms/disease that apply to you ___Allergies ___Asthma ___Frequent cold/flu ___Cough ___Sinus irritation ___Excess Phlegm/mucus ___Shortness of breath ___Acne ___Eczema/Psoriasis ___Stress ___Anxiety ___Depression ___Mood swings ___Insomnia ___Difficulty falling asleep ___Feel unrested after sleep ___Fatigue ___Dizziness ___Hearing loss ___Ringing in ears ___Fainting ___Chest pain ___Palpitations ___High blood pressure ___Low blood pressure ___Swelling ___Anemia ___Diarrhea ___Loose stools ___Constipation ___Hemorrhoids ___Nausea ___Vomiting ___Heartburn ___Abdominal cramps ___Weight gain/loss ___Ulcers ___Frequent urination ___Urination discomfort ___Frequent urinary infections ___Cold hands/feet ___Hot flashes ___Night sweating ___Always cold ___Always hot ___Headaches ___Migraines ___Mental fogginess ___Difficulty concentrating ___Poor memory ___Back pain ___Neck pain ___TMJ/Jaw pain ___Shoulder pain ___Knee pain ___Chronic Pain ___AIDs ___Autoimmune disease ___Arthritis ___Cancer ___Chronic Fatigue/Fibromyalgia ___Diabetes ___Hepatitis ___Rheumatoid Arthritis ___Stroke List any other condition diagnosed by a Medical Professional: _______________________________________________ _______________________________________________ Do you have a pacemaker? Yes/No Circle areas where you experience pain: Sage Earth Acupuncture New Client Intake Form Dayna Meier R. Ac. TCMD _________________________________________________________________________________________________ Females Age when period began:______ How many days of bleeding:________ ___Breast pain/tenderness Length between cycles:________ ___Breast lumps ___Menopause ___Fertility issues ___Irregular cycles ___Fibroids ___PMS ___Endometriosis ___Menstrual cramps ___Cysts ___Heavy periods ___Yeast infections ___Light periods ___Sexually Transmitted Infections ___Clots in period ___Abortions ___Spotting before/after period ___Miscarriage ___Spotting midcycle ___Birth control pill What colour is the period Are you pregnant?______ blood/Menses? Number of pregnancies_____ ___Bright red Number of deliveries_____ ___Pale red Cesarean Sections____ ___Dark red Problems during pregnancy or ___Blackish childbirth:________________________________
___Purplish ____________________________________________ ___Thick List any conditions of reproductive ___Thin, watery organs that have been diagnosed by a Medical Professional: ____________________________________________
____________________________________________ _________________________________________________________________________________________________ Males ___Prostate inflammation ___Low sperm count ___Erectile dysfunction ___Testicular pain/swelling ___Impotence Other:_____________________________________
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