I General Information
Name
Date
Address
Married
City
Single
Partner
Divorced
Home Phone
State
Widowed
Date of Birth
Work Phone
Cell Phone
Email
Occupation
Emergency Contact
Referred By
Family Physician
Zip
Contact #
May we contact them? Y/N
Have you had Acupuncture or Oriental medicine before? Y/N
Are you presently under a doctor’s care? Y/N
Who and for what?
Are there any other therapies which you are involved?
Who and for what?
II Focus
What is your primary reason for seeking care at our office?
1.
2.
3.
What was the initial cause?
What makes it worse?
What makes it better?
What have you done
ᴏ MRI
ᴏ CT Scan
ᴏ X-Rays
ᴏ Blood Tests
ᴏ Physical Therapy
about this?
ᴏ Chiropractic ᴏ Massage Therapy ᴏ Pain Clinic ᴏ Pain Medicine
ᴏ Other
List any other health challenges:
List any past or future surgeries:
List any significant trauma. When did they occur? (auto accident, falls, emotional, sexual, etc.)
III Patient Intake Organ Function
Please check the following that currently pertain to you (if you have symptoms in the following categories, it indicates
that you have a possible problem with that organ’s function).
Lung Function / Large Intestine Meridian / Organ Network
ᴏ Difficulty Breathing
ᴏ Loose Stools
ᴏ Dry Skin
ᴏ Excess Phlegm
ᴏ Tuberculosis
ᴏ Sweating
ᴏ Smoke (__ per day)
ᴏ Sadness
ᴏ Difficulty Concentrating
ᴏ Frequent Colds/Flu
ᴏ Psoriasis
ᴏ Sinusitis
ᴏ Shortness of Breath
ᴏ Cough
ᴏ Rapid, Quick Thinking
ᴏ Slow Healing Skin
ᴏ Pulmonary Diseases
ᴏ Nasal Problems
ᴏ Constipation
ᴏ Melancholy
ᴏ Asthma
ᴏ Mucus in Stool
ᴏ Diarrhea
ᴏ Chest Congestion
ᴏ Wheezing
ᴏ Emphysema
ᴏ Bottle fed as child
ᴏ Allergies
ᴏ Other ____________
Sensitivities to: ᴏ Smells ᴏ Noise ᴏ Clothing ᴏ Energy ᴏ Other ____________
Kidney / Urinary Bladder Meridian / Organ Network
ᴏ Frequent Cavities
ᴏ Memory Problems
ᴏ Easily Startled
ᴏ Sciatica
ᴏ Diseases of the Spinal Column
ᴏ Knee Pain
ᴏ Heat in Chest
ᴏ Unusual Urine out-put
ᴏ Dental Problems
ᴏ Excessive Hair Loss
ᴏ Fatigue / Lethargy
ᴏ Decreased Will Power
ᴏ Osteoarthritis
ᴏ Afternoon flushes
ᴏ Lack of Perspiration
ᴏ Kidney Stones
ᴏ Frequent Night Urination
ᴏ Cold Hands or Feet
ᴏ Multiple Sclerosis
ᴏ Infertility
ᴏ Hot Body Temperatures
ᴏ Perspire Easily
ᴏ Easily Broken Bones
ᴏ Lack of Bladder Control
ᴏ Depression
ᴏ Muscular Dystrophy
ᴏ Sterility
ᴏ Excessive Thirst
ᴏ Hot Flashes
ᴏ Low Back Pain
ᴏ Fear
ᴏ Premature Gray Hair
ᴏ Cerebral Palsy
ᴏ Cold Body Temperature
ᴏ Night sweats
Liver / Gall Bladder Meridian / Organ Network
ᴏ Anger Easily
ᴏ Tightness in chest
ᴏ Gall stones currently
ᴏ Headaches on side of head
ᴏ Liver Spots
ᴏ Brittle/Course Nails or Hair
ᴏ Cramping
ᴏ Menstrual Cramping
ᴏ Hiccups
ᴏ TMJ
ᴏ Frustration
ᴏ Bitter Taste in Mouth
ᴏ Seizure
ᴏ PMS Symptoms
ᴏ Substance Abuse
ᴏ Distention/Bloating
ᴏ Irritable Bowel
ᴏ Vertigo
ᴏ Belching
ᴏ Stiff Neck & Shoulders
ᴏ Depression
ᴏ Tingling Sensations
ᴏ Convulsions
ᴏ Fibromyalgia
ᴏ Chronic Fatigue
ᴏ Flushed Face
ᴏ Sensitivity to greasy foods
ᴏ Tinnitus
ᴏ Sour Regurgitation
ᴏ Restless Legs
ᴏ Irritability
ᴏ Numbness
ᴏ Skin Rashes
ᴏ Nausea
ᴏ Parkinson’s Disease
ᴏ Muscle Spasms
ᴏ Migraines
ᴏ Insomnia
ᴏ Compulsion to Exercise
ᴏ Anxiety Disorder
○ Pain in the Ribs
○ Gall Stones History
○ Drink Alcohol
○ Tendonitis
○ Migratory Pain
○ Twitching
○ Tremors
○ Staying Asleep
○ Sighing
○ Stroke
ᴏ Repetitive Strain Disorders (Please list) ______________________________________________________________________________________
Heart / Small Intestine / Organ Network
○ Mental Confusion
○ Restlessness
○ Sores on Tip of Tongue
○ Drink Coffee __ # cups/day
○ Abdominal Pain
○ Phobias
○ Muscle Tone
○ Urinary Problems
○ Belching
○ Palpitations
○ Dizziness
○ Wake Unrefreshed
○ Dream Disturbed Sleep
○ Hot Flashes
○ Poor Circulation
○ Psychosis
○ Cardiac Pain
○ TMJ
○ Chest to Shoulder Pain
○ Vertigo
○ Difficulty Falling Asleep
○ Heart Problems
○ Hot Painful Joint
○ Rheumatoid Arthritis
○ Epilepsy
○ Shortness of Breath
○ Difficulty Staying Asleep
○ Flushed Face
○ Anxiety
○ Hearing Problems
○ Inflammatory Conditions
○ Tongue/Speech Problems
○ Spontaneous Sweating
○ Sour Regurgitation
○ Nightmares
○ Cold Limbs
○ Pain Down the Arm
○ Anemia
○ Disturbed Thinking
○ Lack of Joy/Humor
○ Upper Back Pain
○ Bitter Taste in Mouth
Spleen / Stomach Meridian / Organ Network
ᴏ Low Appetite
ᴏ Abrupt Weight Gain
ᴏ Over-Thinking/Worry
ᴏ Vomiting
ᴏ Gurgling Noise in Stomach
ᴏ Chronic Disease
ᴏ Loose Stools
ᴏ Difficulty Focusing
ᴏ Insomnia
ᴏ Excessive Appetite
ᴏ Abrupt Weight Loss
ᴏ Abdominal Bloating
ᴏ Ulcer (diagnosed)
ᴏ Cancer
ᴏ Irritable Bowel
ᴏ Non-Breast Fed
ᴏ Hemorrhoids
ᴏ Acid Reflux
ᴏ Fatigue After Eating
ᴏ Bad Breath
ᴏ Belching
ᴏ Burning Sensation After Eating
ᴏ Diabetes
ᴏ Weak Muscles
ᴏ Fatigue
ᴏ Excess Phlegm
ᴏ Heartburn
ᴏ Easily Bruised
ᴏ Stomach Pain
ᴏ Passing Gas
ᴏ Prolapsed Organs
ᴏ Gastritis
ᴏ Headaches
ᴏ Vein Problems
ᴏ Crohn’s Disease
ᴏ Mouth Sores
ᴏ Nausea
ᴏ Nausea
ᴏ Hiccups
ᴏ Aching Heavy Limbs
ᴏ Indigestion
ᴏ Poor Memory
ᴏ Bitter Taste in Mouth
IV Female Concerns
Date of last menstruation:
Birth control? Y/N How long?
Is your cycle regular? Y/N Is your cycle painful? Y/N Have you ever been pregnant? Y/N
ᴏ PMS ᴏ Clotting ᴏ Vaginal sores ᴏ Vaginal pain ᴏ Discharge
V Medical History
Do you have any allergies? Y/N If so, to what?
Do you take medication?
Y/N If so, what types and how often?
Do you take supplements? Y/N If so, what types and how often?
Please indicate if you or any family members have or had any of the following conditions:
ᴏ Pneumonia
ᴏ Tuberculosis
ᴏ Hepatitis
ᴏ Diabetes
ᴏ Epilepsy
ᴏ Kidney Stone
ᴏ Drug Reaction
ᴏ Heart Attack
ᴏ Blood transfusion
ᴏ Anemia
ᴏ Arthritis
ᴏ Obesity
ᴏ Mental breakdown
ᴏ Jaundice
ᴏ Parasites
ᴏ Measles
ᴏ Mumps
ᴏ Syphilis
ᴏ Gonorrhea/Herpes
ᴏ HIV/Aids
ᴏ High/Low blood pressure
ᴏ Heart disease
ᴏ Gout
ᴏ Cancer
ᴏ Mental Illness
ᴏ Hypo/hyper thyroid
ᴏ Premature graying
ᴏ Seizures
ᴏ Multiple Sclerosis
Do you sleep well? Y/N
Do you dream Y/N
Do you have a high point during the day? Y/N When?
Do you have a low point during the day? Y/N When?
What are your indulgences?
What are your hobbies/pleasures?
VI Web of Wellness
ness ss
Health and wellness is a balance
of many things. Many factors
affect our lives in various ways.
These factors weave a web of
health and well-being.
Using the diagram, starting at the
center, choose your level of
satisfaction in each of these
areas.
Mental Health
Physical Health
Sexual
Health
Financial
Health
Career
Health
Spiritual
Health
For example, if you are extremely
satisfied with your career, shade
in the #10 Career circle.
1 = Not Happy
10 = Extremely Satisfied
Social Health
Family Health
VII Pain
Please indicate areas of pain/tension/tightness/discomfort on chart.
Trauma/Scar Chart
Pain intensity levels
○ No Pain ○ Moderate Pain ○ Severe Pain ○ Terrible Pain
Sleeping
○ No Problem ○ Mildly disturbed ○ Greatly disturbed ○ Greatly disturbed
Work Performance
○ Usual Work ○ 25% of work ○ 50% of work ○ No Work
Frequency of Pain
○ 25% of time ○ 50% of time ○ 75% of time ○ 100% of time
Travel
○ No problem on long trips ○ Moderate pain ○ Severe Pain
Recreation
○ All activities ○ Some activities ○ No activities
Walking
○ Can walk any distance ○ Pain after ½ mile ○ Cannot walk
Sitting
○ No Pain Sitting ○ Some Pain while sitting ○ Cannot sit
Mark any scar/trauma with an ‘x’ and brief description.
VIII Other Health Factors
Are you Whole Body Health minded or do you only want to work on your main area of complaint?
ᴏ Whole Body Health ᴏ Main Area of Complaint
Do you exercise or have a routine? Explain:
What do you need to do for your body to heal?
Are you happy?
Do you like your work?
Do you consider yourself healthy?
How long do you want to live?
On a scale of 0-10, how much do you believe the body can heal itself?
Is there anything keeping you from being the most authentic, vital you?
What do you love about yourself?
What is missing from your life?
What rules/habits do you follow that you wish you could break?
IX Commitment to Health
Please check which level of commitment you are willing to make
Definitely will
Probably will
Probably won’t
Definitely won’t
Full Course of Acupuncture treatments
Taking herbs/supplements
Dietary Changes (Living Foods)
Targeted home exercise therapy
Lifestyle/exercise plan
Balancing sleep/rest
Stress Management
Detoxifying the body
Necessary water intake
Types of Care
Acute or Relief Care
Stabilization Care
Wellness & Preventative Care
Obvious symptoms and signs
Symptoms and signs disappear
You feel great
Get me out of pain and discomfort fast!
Feeling good, no big problem!
Feeling great! Life is wonderful!
Most patients begin acupuncture
treatment to provide relief from pain,
discomfort and other symptoms, fast.
Acute Care helps to ease your initial
problem(s) quickly.
Stabilization Care gives you a change for
deeper healing to occur. Strengthening
your body’s response to illness by
stimulating your natural healing powers.
I want to achieve optimal health and wellbeing, free of disease and illness.
Wellness Care is your best choice.