Boulder East West Acupuncture, LLC
Confidential Patient Intake Form
Patient Information
Name:
Date:
Address:
Phone:
Email:
Best way to reach you:
Age:
Call
Text
Birth Date:
Email
Sex:
Marital Status:
Height:
Weight:
Occupation:
Years:
Emergency Contact Person & Phone Number:
Relationship:
Who referred you to this office?
Main Reason for This Visit:
Known Diagnoses or Health Problems:
Personal Health Goals:
Present/Previous Doctor & Phone Number:
Other practitioners involved in your care (Please list, including specialty):
Past Medical History (Please list or describe):
Year/Date
Operations or surgery:
Year/Date
Head Injury:
Hospitalizations:
Accidents:
Serious Illnesses:
Broken Bones:
Blood Transfusions:
Pacemaker:
Other:
Allergies & Sensitivities
Please list any medications or drugs, and any foods or other substances to which you are allergic:
Information from this intake form is used by the practitioner to create a holistic picture of the patient’s health. All information is strictly confidential.
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Boulder East West Acupuncture, LLC
Confidential Patient Intake Form
Are you currently or have you been in the past exposed to any of the following?
Chemicals_____Radiation_____Paints_____Fumes_____Dust_____Solvents_____Contaminated Water_____
Travel to 3rd World Country_______________________________________________________________________
Wilderness Areas________________________Other__________________________________________________
Number of courses of antibiotics:
Number of courses of steroids:
Medications & Supplements
List all medications you are taking (including over the
List any vitamin, herb, or
counter meds and birth control pills – past or current):
supplements you are taking:
Name:
Name:
Dose:
Frequency:
Dose:
Frequency:
Health Habits
Check YES or NO and circle day or week:
Tobacco smoking:
Yes
No
packs per day/week
Type of tobacco
Coffee:
Yes
No
cups per day/week
Regular
Decaf
Tea:
Yes
No
cups per day/week
Regular
Herbal
Alcohol:
Yes
No
drinks per day/week
Wine Beer Liquor
Artificial Sweeteners
Yes
No
packs per day/week
Glasses water/fluid per day
plain water
juice
other
What exercises/activities do you do and how often?
Mark the stress level in your life (0 is the least, 10 is the most):
How much does stress affect you (0 is the least, 10 is the most)?
What is your job satisfaction (0 is the least, 10 is the most)?
What are the major stresses in your life presently?
How many hours per week do you work?
How many hours per week do you have for free time?
How many hours of sleep do you get per night?
Is it restful?
Do you have an adequate energy level?
Favorite pastime/recreational activity:
Information from this intake form is used by the practitioner to create a holistic picture of the patient’s health. All information is strictly confidential.
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Boulder East West Acupuncture, LLC
Have you ever had any of the following?
Indicate “C” for current or “P” for past:
GENERAL
____ fever
____ chills
____ abnormal sweating
____ night sweats
____ fatigue
____ irritability
____ depression
____ generally feel “run down”
____ sexual abuse (optional)
____ emotional abuse (optional)
____ loss of weight
SKIN
____ non-healing sore
____ hives, rash
____ eczema, psoriasis
____ frequent infection or boils
____ abnormal pigmentations, moles
____ warts
____ herpes
____ lips
____ genital
____ zoster (shingles)
____ skin cancer or melanoma
____ brittle or weak nails
____ infected nails
ENDOCRINE
____ diabetes
____ thyroid disease
____ heat intolerance
____ cold intolerance
____ aversion to wind
____ dry skin
____ change in hair growth or texture
____ excessive thirst
____ diminished thirst
____ insatiable appetite
____ lack of appetite
____ sexual problems
____ hormone therapy
____ low or high sex drive
____ radiation to the neck or face area
____ low blood sugar
HEAD-EYES-EARS-NOSE-THROAT
____ headache
____ sinus (allergy)
____ tension
____ migraine
location:________
____ head feels “heavy”
____ memory loss
Confidential Patient Intake Form
____ light-headedness or “spaciness”
____ sensitivity to light
____ red eyes
____ blurry vision
____ double vision
____ loss of vision
____ night blindness
____ glaucoma, cataracts
____ loss of balance
____ dizziness or vertigo
____ loss of hearing
____ ear disease
____ impaired hearing
____ ringing or buzzing in ears (tinnitus)
____ low-pitched
____ high-pitched
____ ear pain
____ discharge from ear
____ runny nose or nasal discharge
____ nosebleeds
____ chronic sinus trouble
____ snoring
____ sleep apnea
____ sore throat
____ hoarseness
____ tooth and gum problems
____ bleeding gums
____ loose teeth
____ sores in mouth
____ sore tongue
____ bad breath
____ loss of taste
____ taste in mouth
____ bitter
____ metallic
____ sour
____ sweet
RESPIRATORY
____ frequent colds
____ difficulty breathing
____ chronic or frequent cough
____ asthma or wheezing
____ emphysema
____ spitting up blood
____ pleurisy (pain with breathing)
____ pneumonia
____ coughing up sputum
CARDIOVASCULAR
____ high blood pressure
____ palpitations
____ irregular heart beat
____ rheumatic fever
____ chest pain or angina
____ shortness of breath with walking
____ shortness of breath lying down
____ difficulty walking two blocks
____ heart trouble
____ heart attack
____ heart murmur
____ atrial fibrillation
____ awakening in the night smothering
____ swelling of hands, feet, or ankles
____ need more than one pillow to sleep
____ varicose veins
____ pain in calves relieved by rest
HEMATOLOGIC
____ excessive bleeding/bruising
____ anemia
____ phlebitis/blood clots in veins
____ slow healing cuts or bruises
____ excessive bleeding after dentist
____ mononucleosis
GASTROINTESTINAL
____ painful bowel movements
____ incomplete bowel movements
____ alternating constipation/diarrhea
____ vomiting food or blood
____ heartburn/indigestion
____ food sticks in throat
____ difficulty swallowing
____ diarrhea or loose stools
____ constipation
____ ulcer (stomach or duodenal)
____ gallbladder disease or stones
____ liver trouble/hepatitis
____ bloody or black stools
____ “nervous” stomach
____ nausea and/or vomiting
____ bloating in stomach after eating
____ bloating or gas in lower abdomen
____ feeling tired after meals
____ thin or ribbon-like stools
____ pellet like stools
____ sticky stools
____ hard stools
GENITOURINARY
____ frequent urination
____ scanty urination
____ involuntary loss of urine
____ burning or painful urination
____ blood in urine
____ straining to urinate
____ hernia
____ sexually transmitted infection
____ kidney stones
____ kidney infections
Information from this intake form is used by the practitioner to create a holistic picture of the patient’s health. All information is strictly confidential.
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Boulder East West Acupuncture, LLC
FEMALE
____ last menstrual period ____ date
____ currently pregnant
____ age periods started ____
____ duration of flow ____ days
____ days in cycle ____ days
____ heavy flow
____ scanty flow
____ clots
size: ____ dime ____ quarter
____ color of menses
____ bright red
____ watery red
____ dark red
____ brown
____ purple
____ abnormal PAP smear
____ pelvic pain or infections
____ excess discharge
____ PMS
____ Premenstrual Dysphoric Disorder
____ menstrual cramping
____ mid-cycle pain
____ irregular cycle
____ breast pain or tenderness
____ breast lumps
____ nipple discharge or bleeding
____ number of pregnancies
____ number of children
____ number of ectopic pregnancies
____ number of miscarriages
____ number of abortions
____ DES (diethylstilbestrol) exposure
____ uterine fibroids
____ hysterectomy
____ date of menopause
____ hot flashes
____ night sweats
____ menopausal bleeding
MALE
____ testicular pain/swelling
____ urinary frequency or burning
____ difficulty starting stream of urine
____ discharge from penis
____ frequent night urination
____ prostate pain/swelling
____ undescended testicle
____ impotence
____ sexual dysfunction
MUSCULOSKELETAL
____ joint swelling
____ arthritis or joint pain
____ weakness of muscles or joints
____ back pain (see next page)
____ difficulty walking
____ leg cramps
____ leg ulcers
Confidential Patient Intake Form
NEUROLOGIC
____ fainting spells
____ epilepsy/seizures
____ stroke or mini-stroke
____ paralysis
____ weakness of an arm or leg
SLEEP
____ insomnia or trouble sleeping
____ difficulty falling asleep
____ difficulty staying asleep
____ waking often at night
____ vivid dreams
____ exhausting dreams
time to sleep ____
time to wake ____
wake feeling rested? ____ yes ____ no
EMOTIONS
Tendency towards:
____ sadness/grief/depression
____ anger/irritability
____ anxiety/fear
____ mental overactivity
____ grief
NECK
____ stiffness
____ pain
____ pain with movement
____ forward
____ backward
____ turning to the left
____ turning to the right
____ bending to the left
____ bending to the right
____ pinched nerve in neck
____ neck surgery
____ neck feels out of place
____ muscle spasms in neck
____ grinding sounds in neck
____ popping sounds in neck
____ arthritis in neck
____ swollen glands
SHOULDERS
____ pain in joint (Right or Left)
____ pain across shoulders
____ bursitis (R/L)
____ arthritis (R/L)
____ cannot raise arm
____ past shoulder level
____ over head
____ cannot put arm behind back
____ tension in shoulders
____ pinched nerve in shoulder (R/L)
____ muscle spasms in shoulders
____ thoracic outlet syndrome
ARMS AND HANDS
____ pain in upper arm (R/L)
____ pain in elbow (R/L)
____ movement increases pain
____ pain in forearm (R/L)
____ pain in hands (R/L)
____ pain in fingers (R/L)
____ pins & needles in arms (R/L)
____ pins & needles in fingers (R/L)
____ numbness in arms (R/L)
____ numbness in fingers (R/L)
____ fingers go to sleep (R/L)
____ cold hands (R/L)
____ swollen joints in fingers (R/L)
____ arthritis in fingers (R/L)
____ loss of grip strength (R/L)
MID-BACK & CHEST
____ mid-back pain
____ pain between shoulder blades
____ sharp, stabbing pain
____ dull ache
____ pain from front to back
____ muscle spasms in mid-back
____ pain in kidney area
____ chest pain
____ shortness of breath
____ pain around ribs
____ pain below ribcage
LOW BACK
____ low back pain
____ sacroiliac pain
____ slipped disk
____ low back feels out of place
____ muscles spasms
____ sharp pain
____ dull ache
____ feeling of coldness
Pain is worse when:
____ working
____ lifting
____ stooping
____ standing
____ sitting
____ bending
____ coughing
____ lying down (sleeping)
____ walking
____ other ____________
Pain is relieved with:
____ ice
____ heat
____ movement
____ physical therapy
____ topical analgesics
____ medications
____ other ____________
Information from this intake form is used by the practitioner to create a holistic picture of the patient’s health. All information is strictly confidential.
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Boulder East West Acupuncture, LLC
HIPS, LEGS, & FEET
____ pain in buttocks (R/L)
____ pain in hip joint (R/L)
____ pain down leg (R/L)
____ pain down both legs
____ knee pain (R/L)
____ leg cramps (R/L)
____ restless legs
____ pins and needles in legs (R/L)
____ numbness of leg (R/L)
____ numbness of feet (R/L)
Confidential Patient Intake Form
____ numbness of toes (R/L)
____ feet feel cold (R/L)
____ swollen ankles (R/L)
____ swollen feet (R/L)
THERAPEUTIC TECHNIQUES
____ acupuncture
____ herbal medicine
____ massage
____ chiropractic
____ physical therapy
____ psychotherapy (optional)
____ homeopathy/flower essences
____ Feldenkrais/Alexander technique
____ Reiki
____ craniosacral
____ others ____________________
______________________
____________________
Please circle areas of pain or discomfort on the figure below.
Also number the pain between 1 and 10, with 1 being the least pain, and 10 being the most.
Information from this intake form is used by the practitioner to create a holistic picture of the patient’s health. All information is strictly confidential.
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