Kristen Barritt, RN L.Ac
New Patient Intake
Name: _____________________________________________________________________________________________________________
Date of Birth: _____________________
Age: _____________
Sex: ____________
Address: ________________________________________________________
Phone: ___________________________________
Marital Status: __________________
City/State/Zip: _____________________________
Email: ______________________________________________________________
Occupation: ___________________________________________
Employer: ____________________________________________
Emergency Contact (name/relation/phone) __________________________________________________________________
Referred by: _____________________________________________
Physician Name: _________________________________________________
Address:________________________________________________________
Date of last physical exam:_____________
Phone: ____________________________________
City/State/Zip: _____________________________
Date of most recent blood work (attach if possible):___________
Any Western Diagnoses:________________________________________________________________________________________
What would you like to be treated for?__________________________________________________________________________________
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Please describe your current medical problem. Please include how and when it began, any treatment you’ve had
thus far, any testing (labs, imaging, etc), any relieving or aggravating factors, and any other information you feel
would be helpful.
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Medical History
Previous Surgeries/Hospitalizations
Reason
Date
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Current Medications (including over the counter)
Reason
Dosage
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How many courses of antibiotics have you had in the last 5 years? _____________________________________________________
Current Supplements
Reason
Dosage
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Allergies (drugs, seasonal, environmental, etc)
________________________________________________________________________________________________________________________________
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Family Medical History
Father: Age ____________
Please circle: Good health
Poor health
Deceased (cause ________________)
Mother: Age ____________
Please circle: Good health
Poor health
Deceased (cause ________________)
(Please indicate if you or an immediate family member has/has any of the following conditions)
Cancer ______________
Heart disease ______________
High blood pressure _______________
Diabetes ______________
Kidney disease ______________
Bleeding disorders _______________
Epilepsy ______________
Tuberculosis
______________
Alcoholism/Addictions ____________
Arthritis ______________
Mental Illness ______________
Depression/Anxiety _______________
Asthma _______________
Stroke/TIA
Osteoporosis
_________________
Birth defects
_________________
_______________
Alzheimer’s/ Parkinson’s Disease _____________________
Autoimmune disorders (which disorder?) _______________________________________________________________________
Other (please specify) ______________________________________________________________________________________________
Lifestyle History
Current Weight: ______________
Do you exercise?
Y
N
Height: ______________
Max Weight: _____________
When? _______________
If yes, what do you do, for how long and how often? _____________________
______________________________________________________________________________________________________________________
Do you smoke?
Y
N
If yes, how much and for how long? ________________________________________
Previously smoked?
Y
N
If yes, how much and for how long? ________________________________________
Do you drink alcohol? Y
N
If yes, how much and how often? ___________________________________________
Recreational drug use? Y
N
Have you been treated for drug/ alcohol addiction?
Sleep __________ hours/night
Enjoy your work?
Y
N
Y
N
Easy to get to sleep and stay asleep? Y
N
Awake rested?
Y
N
Have a good support system?
N
History of abuse? Y
N
Y
Average stress level (circle): (low) 1 2 3 4 5 6 7 8 9 10 (high)
Average energy level (circle): (low) 1 2 3 4 5 6 7 8 9 10 (high)
What time of day is your energy highest? ________________________
lowest? ___________________________
What’s your predominant emotion? ____________________________________________________________________________
Circle any that apply:
Easily irritated
Depressed
Worry a lot
Cry easily
Angry
Indecisive
Hurry to do things
Typical Food Intake
Breakfast: _________________________________________________________________________________________________________
Lunch: _____________________________________________________________________________________________________________
Dinner: ____________________________________________________________________________________________________________
Snacks: ____________________________________________________________________________________________________________
Beverages: ________________________________________________________________________________________________________
How much water do you drink in a day? (Iced, room temp, warm, hot?) ___________________________________
Do you eat 3 meals a day?
Y
N
Eat out often?
Y
N
Do you drink coffee/ black tea?
Y
N
If yes, how much? ____________________________
Do you drink soda pop?
Y
N
If yes, how much? ____________________________
Men’s Health (men only please) Please circle below as pertains to you
Hernia
Testicular masses
Testicular pain
Penile discharge/sores
Sexual difficulties
Impaired fertility
Are you sexually active?
STI/STD’s
Y
N
Y N
Prostate problems (Date of last exam? _______________________)
(If yes, what type?_____________________________________)
Women’s Health (women only please)
Age of first menstruation ____________________
Age of menopause
_____________________
Date of last pap smear
____________________
Number of pregnancies _____________________
Number of live births
____________________
Number of miscarriages ____________________
Birth control
Y
N
If yes, what type? ____________________________________________________________
Hysterectomy
Y
N
If yes, when? _________________________ Full or partial? ____________________
Abnormal pap smear? Y N
If yes, when? _________________________
Please circle below as pertains to you
Self breast exams
Breast lumps
Breast pain
Nipple discharge
Endometriosis
Ovarian cysts
Fibroid tumors
Frequent yeast infections
Impaired fertility
Sexual difficulties
Are you sexually active? Y N
STI/STD’s?
Y N (If yes, what type?_______________________________________)
If you are still menstruating
Length of cycle _____________
Irregular cycles
PMS
Y
N
Length of flow (days) _____________
Painful menses
Spotting
Heavy flow
If yes, what are your symptoms? ________________________________________________________________________
_______________________________________________________________________________________________________________________________
If you are in menopause please circle below as pertains to you
Hot flashes
Vaginal dryness
Changes in memory
Dry skin
Spotting
Decreased libido
Mood changes
Hair loss
Urinary incontinence
Urinary tract infections
Hormone replacement
Y
N
If yes, what type? _______________________________________________
Review of Systems
Body temperature:
 Normal
 Warm natured  Flushed face
 Warm palms
 Warm soles
 Cold hands / feet
 Alternate chills and fever
 Other
Perspiration:
 Normal
 Without exertion
 Very little
 Palms
Digestion:
 Normal
 Bitter taste in mouth
 Nausea/vomiting
 Abdominal pain or cramps
 Easily
 Strong odor
 Night sweats
 Spontaneous without exertion
 Indigestion
 Belch or burp
 Bloating
 Bad breath
 Stomach noises
 Gas
 Difficulty digesting fatty / oily foods
Bowels: How many times per day? _______________________
 Normal
 Loose stool
 Undigested food in stool
 Pain or cramps
 Stool with bad smell
 Use laxatives
 Small amount of stool
 Intestinal worms
 Black stool
 Other
Thirst:
 Normal
 Less than normal
 Thirsty but do not drink
 Excessive
 Other
Headaches – Dizziness:
 Headaches
 Vertigo
 Bend down and get up / get dizzy  Migraines
 Poor balance
 Other
 Heartburn
 Gallstones
 Full feeling or distention
 Weight problems
 Nervous stomach
 Other
 Profuse
 Cloudy
 Strong smell
 Clear/yellow
 Kidney stones or infections
 Prefer cold drinks
 Awake easily
 Sleep too much
Restless
Lots of dreams
 Other
 Profuse
Other
 Blood in stool  Diarrhea
 Hemorrhoids  Hard stool
 Constipation  Difficult to pass stool
 Mucous in stool  Burning Anus
Urination: (three to four times a day is normal)
 Normal
 Frequent
 Burning
 Urgency
 Painful
 Scanty
 Nighttime
 Blood
 Not normal color
 Bladder infections
Sleep:
 Normal
 Difficulty falling asleep
 Tired when waking up
 Cold natured
 Feel warmer late afternoon/evening
 Incontinence
 Other
 Prefer hot drinks
 Difficulty getting back to sleep
Nightmares
 Motion sickness Dizziness
 Poor memory  Faint easily
Skin:
 Normal
 Cuts heal slowly
 Bruise easily
 Dry
 Pimples
 Body odor
 Hives
 Rashes
 Yellow skin
 Clammy
 Moles
 Other
 Ulcers
 Itching
 Warts
 Eczema
 Boils
 Oily
Hair:
 Normal
 Dry
 Oily
 Dandruff
 Falling out
 Early grey
 Other
Nails:
 Normal
 Ridges and lines
 Soft
 Purple
 Grow fast
Break easily
 Grow slowly
 Other
 Spots
 Pale
Eyes:
 Normal
 Color blindness
 Sensitive to light
 Inflammation
 Tear easily
 Wear glasses or contacts
 Eyelids swollen
 Poor night vision
 Spots or lines in vision
 Pale under eyelids
 Cataracts
 Dry
 Sty history
 Strain
 Yellow sclera
 Glaucoma
 Itch
 Failing vision
 Twitch
 Red
Blurry vision
 Blink frequently
 Pain
 Other
Ears:
 Normal
 Itching
Nose:
 Normal
Blow nose a lot
 Other
Mouth and Throat:
 Normal
 Feel lump in throat
 Drool a lot
 Sores mouth/tongue
 Discharge
 Hayfever
 Sinusitis
 Difficulty hearing
 Sneeze a lot
 Loss of smell
 Teeth problems
 Grind teeth
 Hoarseness
 Frequent sore throats
Mucous
 Bleeding
Pain:
 Low back
 Hands or wrists
 Foot or ankle
 Damp weather
 Chest pain
 Murmur
 Palpitations
 Bleed easily
 Varicose veins
 Shoulder
 Sciatica
 Nerve
 Other
 Rhinitis
 Stuffy nose
 Environmental sensitivity
 Dry
 Frequent colds
 TMJ
 Swollen glands
 Frequent sinus infections
 Difficulty swallowing
Respiratory:
 Normal
 Chest pain
 Dry cough
 Difficulty inhaling
 Sighs
 Bronchitis
 Difficulty breathing w/lying down
Cardiovascular / Circulaion:
 Normal
 High blood pressure
 History of anemia
 Slow beating heart
 High cholesterol
 Broken blood vessels/capillaries
 Ring (low/high pitched)  Other
 Mid back
 Hips
 Arthritis
 Cough a lot
 Difficulty exhaling
 Cough w/blood
 Tightness in chest
 Hiccups
 Thyroid problems
 Gum problems
 Other
 Shortness of breath
 Cough with phlegm
 Asthma
 Other
 Facial swelling  Low blood pressure
 Ankle swelling  Diagnosed heart problems
 Hand swelling  Irregular heart beat
 Bruise easily  Purple palms/fingers
 Numbness in extremities
 Other
 Upper back
 Neck  Foot/ankle
 Knees  Spine Muscle weakness
 Flank area
Muscle twitching
Any other problems you would like to discuss? ______________________________________________________________________
Thank you for taking the time to answer the questions above.
I certify that the information I have given above is correct and accurate to the best of my knowledge.
____________________________________________________________________________
Patient or Guardian signature
____________________________________________________________________________
Printed patient name
______________________________
Date
Practitioner Notes:
Tongue: __________________________________________________________________________
Pulse: R: ______________________________________________ L: ______________________________________________________________
TCM DX: _______________________________________________________________________________________________________________
Points:
Gua Sha
Moxa
Cupping
Tui Na
Auricular: