10692 FM 346
Flint, TX 75762
903-787-9500
www.tyleracupuncture.com
Patient Intake Form
Welcome to Tyler Acupuncture and Wellness. Please help us provide you with a complete evaluation by taking the time
to fill out this questionnaire carefully. Even though some of the questions may seem unrelated to your condition,
Oriental Medicine looks at the person as a whole, even the small details play a role in your diagnosis and treatment. All
of your information will be confidential and if you have any questions, please ask. Thank you.
Contact Information
Today’s Date _______________________
Name:__________________________________________________ Sex: F__ M__ DOB:___/___/___ Age:___
Street:___________________________________________ Email Address:____________________________
City:____________________ State:________ Zip:_______ Phone Number:____________________________
Marital Status: M
S
D
W
# of Children:_____ Alternative Phone Number:__________________
Occupation:______________________________________ Employer:________________________________
Emergency Contact:_________________________ Phone:_________________________________________
Referred By:______________________________________________________________________________
Have you had acupuncture before? Y
N
Allow email/mail/phone contact by TA&W? Y
N
Major Health Complaint(s)
Please list in order of significance to you and check which you would like us to focus on today.
1.
4.
2.
5.
3.
6.
When did the checked problem begin?___
What are the precipitating factors?
__
__
_
Have you been given a diagnosis for this problem? If so, please describe.__
What kind of treatments have you tried?
What makes this problem worse?
Is there anybody in your family with the same problem?
__
Better?
_
__
__
____
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Please describe how these conditions affect or impair your daily activities? Examples may include your overall quality of
life, work, family life, hobbies or self-esteem.
___
___
Past Medical History
Check any conditions that you have had in the past or are currently experiencing: P=Past C=Current
P C
P C
P C
P C
Alcohol/Drug Abuse
Digestive Disorder
Hypertension
Nervous Disorder
Anemia
Epilepsy/Seizures
Jaundice
Pneumonia
Arthritis
Glaucoma
Kidney Disease
Stroke
Asthma
Heart Disease
Liver Disease
Thyroid Disorder
Auto Immune
Heavy Bleeding/Hemorrhage
Tuberculosis
Blood Transfusion
Hepatitis
Mental Illness
Vein Condition
Cancer
High Cholesterol
Migraines
Venereal Disease
Diabetes
HIV/Hepatitis
Other:
___
Known allergies (food, medications, or other):
___________
Significant trauma (car accident, sports injuries etc.):
___________
Immunizations:
___________
Hospitalizations/Surgeries (procedures and dates):
____________
Dental Procedures (include any silver fillings/mercury amalgams):
___________
Do you have a history of frequent antibiotic use? Please Describe.
Allergy shots? Currently
In the past
___________
Never
Please briefly describe your health as a child. (e.g. allergies/asthma, prone to illness, etc):
___
Family Medical History (please specify family member)
Alcoholism/Drug Abuse
Asthma/Allergies
Cancer
Depression/Mental Illness
Diabetes
Other
Heart Disease
Hypertension
Miscarriage
Osteoporosis
Stroke
___
___
____
___
____
_______
Current Health & Lifestyle
Do you smoke? Y
Do you exercise? Y
N
N
Do you travel frequently? Y
If yes, how many per day?
If yes, how many times per week?
N
Weight: Now
Please Describe.
Have you traveled overseas to ‘developing’ countries? Y
Do you sit in traffic/commute as a daily routine? Y
Height:
For how long?
One year ago
___
N
N
Maximum
@ Year
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How many hours do you sleep in general?
When do you usually go to bed?
Diet
Soft drinks per day
Cups of tea per day
Glasses of water per day
Cups of coffee per day
Alcoholic beverages per week
Do you follow a special diet? ________________________________ Vegetarian____ Vegan____ Other __________
Please describe your average daily diet:
Breakfast:
Lunch:
___
Dinner:
__
Snacks:
__
Foods you tend to crave:
___
Please indicate painful or distressed areas by using the symbol that best describes the feeling:
Mark with appropriate symbols:
X
Sharp / Stabbing
P
Pins and Needles
D
Dull / Aching
N
Numbness
Please rate your current level of pain: Very mild 1
2
3
4
5
6
7
8
9 10 Very severe
Medications and Supplements
Medications you are currently taking and amounts (please include prescription medicines, vitamins, supplements, over
the counter drugs, herbal supplements, etc.):
___
___
___
Profile
Please check any of the following symptoms that currently pertain to you.
General
Cold hands
Cold feet
Sweaty hands
Sweaty feet
Hot body temperature
Cold body temperature
Afternoon flushing
Hot flashes
Profuse perspiration
Lack of perspiration
Perspire easily
Night sweating
Chills
Fever
Strong thirst
Lower back pain
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Frequent cavities
Broken/loose teeth
Weak bones
Dizziness
Emotions
Mood swings
Sadness
Nervousness
Bipolar
Skin
Acne
Dandruff
Hearing loss
Ringing in ears/tinnitus
Early graying of hair
Forgetfulness
Weak knees
Knee soreness
Hair loss
Fainting
Anxiety
Panic attacks
Irritability
Obsessive/Compulsive
Fits of laughter
Depression
Anger
Mania
Dry or Flaky Skin
Eczema
Cold lower back
Cold hips/buttocks
Cold knees
Weak nails
Fear
Frequent worrying
Easily stressed
Hives
Psoriasis
Rashes
Ulcerations/Boils
Neuro-Muscular
Seizures
Paralysis
Lack of coordination
Loss of balance
Tingling in extremities
Muscle spasms
Numbness
Cardiovascular
Heart palpitations
Restless dreams
Chest Pain/Angina
Mental restlessness
Tongue ulcers
Insomnia
Speech impediment
Hallucinations
Nasal dryness
Chronic allergies
Sore throats
Chest congestion
Sneezing
Wheezing
Chest tightness
Difficulty Breathing
Shortness of breath
Respiratory
Persistent cough
Nosebleeds
Sinus congestion
Frequent colds/flu
Gastrointestinal
Indigestion
Abrupt weight gain
Abrupt weight loss
Stomach ache
Acid reflux
Bad breath
Loose stools
Mucous in stools
Fatigue following a meal
Easily fatigued
Gas
Stomach ulcer
Belching
Hiccups
Less than 1 BM per day
Small, hard, dry stools
Hypoglycemia
Strong cravings
Hemorrhoids
Nausea
Vomiting
Mouth ulcers
Constipation
Diarrhea
Lymphatic System/Accumulated Dampness
Swollen hands
Mental fogginess
Swollen feet
Mental sluggishness
Edema in the legs
Edema in the abdomen
Heavy limbs/head
Joint stiffness
Liver/Gall Bladder Function
Headaches
Migraines
Gall stones
Eyes
Itchy eyes
Dry eyes
Blurry vision
Urinary
Cloudy
Low or weak appetite
Gurgling in intestines
Bruise easily
Ravenous appetite
Bleeding gums
Heartburn
Blood in stools
Difficulty moving bowels
Pain in ribcage
Watery eyes
Red and irritated eyes
Small amount
Chronic neck or shoulder tension
Poor night vision
Floaters/Seeing spots
Night-time urination
Cataracts
Glaucoma
Incontinence
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Dark yellow
Clear color
Reddish color
Large amount
Dribbling
Difficulty initiating urination
Very frequent
Strong odor
Pain or burning
Male Only
Prostate Problems
Testicular pain/swelling
Low sex drive
Premature ejaculation
Nocturnal emission
Infertility
Low sperm count
Poor sperm motility
Feeling of coldness or numbness of genitalia
Do you have any bothersome symptoms? Y
Do you get up at night to urinate? Y
Ejaculation problems
Erectile dysfunction/impotence
Difficulty maintaining an erection
Irregular sperm morphology
Discharge
N
N
Describe:
__
How often?
__
To what extent do these conditions interfere with your daily activities (work, sleep, socializing, sex, etc.)?
___
Have you sought medical intervention for these problems? If so, when?
_
___
What treatment have you tried for these problems and how successful have they been?
___
Female Only
Pelvic infection
Fibroids
Breast tenderness
Low sex drive
Endometriosis
Ovarian cysts
Breast lumps
Fertility problems
Vaginal dryness
Abnormal pap smear
Spotting between periods
Pain during intercourse
Frequent vaginal infections
Abnormal vaginal discharge
Hot flashes
Night sweats
Do you experience any of the following associated with your period each month?
Water retention
Migraine/headache
Lower back pain
Mood swings
Irritability
Abdominal cramps
Food cravings
Acne
Heavy bleeding
Clots
Other:
number of pregnancies
number of live births
miscarriages
premature births
difficult delivery
cesareans
At what age did you get your first period:
Change in bowel movement
Breast tenderness/swelling
Scanty/light bleeding
First day of last menstrual period:
Are your menstrual cycles spaced regularly? Y
N
Are you currently using birth control? Y
If yes, what type and for how long?
Have you experienced menopause? Y
abortions
N
N
When?
Cycle length:
_ Period length :
___
_
_____
__
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If you are experiencing menopausal symptoms, please describe
_______________________________________________________________________________________
Is there any possibility you are pregnant now? Y
Patient Signature
N
Date
Page 6 of 6