CALEB GATES, L. Ac, CMT
PATIENT INTAKE FORM-ACCUPUNCTURE/MASSAGE
DATE: ______________
Name______________________________ Date of Birth__________________
Chief Complaint Currently__________________________________________________________
_______________________________________________________________________________
Additional Health Priorities:
1.______________________________________________________________________________
2.______________________________________________________________________________
3. ______________________________________________________________________________
4.______________________________________________________________________________
Drugs/Supplements Currently Taking__________________________________________________
________________________________________________________________________________
Drug Allergies___________________________________________________________________
If you have had any of the following, please describe the type and the date it occurred.
Surgeries_______________________________________________________________________
______________________________________________________________________________
Major Trauma/Injuries_____________________________________________________________
Blood Transfusions_______________________________________________________________
Primary Care Physician________________________ (Name of current Physician you are seeing)
Lifestyle & Diet (Check all that apply and describe)
Your job is associated with potentially harmful chemicals______________________________
Your job consists of life threatening activities________________________________________
You smoke (starting date & # of packs per day)_____________________________________
Have you ever smoked (starting & stopping date)____________________________________
You use smokeless tobacco (starting date)__________________________________________
You drink caffeinated beverages (# cups per day)____________________________________
You drink alcohol (circle below # of drinks/week)
1) 0
2) 1-3
3) 4-7
4) 8-14
5) 15-20
6) Over 20
You’ve been concerned in the last year about your alcohol consumption
Take/n addictive or habit forming drugs (circle below)
1) Regular Use
2) Sporadic Use
3) Intravenous Drug Use
You have food allergies_________________________________________________________
You’re on a special diet_________________________________________________________
You eat red meat (# of times/week)_______________________________________________
You consume milk and/or dairy products (# of times/week)____________________________
You have cravings for certain foods or tastes________________________________________
You have a regular bedtime (# of hours of sleep/night)_______________________________
1
Is your appetite;
Small
Normal
Strong
Are your emotions;
Stressful
Easily Expressed
Reactive
Weekly exercise is;
1-2 days
3-4 days
5 or more days
Do you exercise for more than 20 minutes at a time?__________________________________
Do you include cardiovascular exercise in your routine?_________________________________
What is your stress level on a scale of 1-10? (1 being low)________________________________
What are your major causes of stress?_______________________________________________
What are your stress relief activities?_________________________________________________
General (Check all that apply)
Sweat Easily
Cold Limbs
Recent Weight Loss
Poor Sleeper
Fatigue
Prefer Cold Drinks
Weak Immunities
Hot Flashes
Night Sweat
Cold Body
Feel Warm Mostly
Overweight
Underweight
Memory Problems
Fevers
Normal Energy Level
Feel Thirsty Often
Prefer Warm Drinks
Strong Immunities
High Metabolism
Low Metabolism
Respiratory (Check all that apply)
Coughing
Shortness of Breath
History Sinus Infections
Phlegm
Difficulty Breathing
Asthma
Tight Chest
Allergies
History Pneumonia
Do you have any respiratory diseases diagnosed by an MD?_____________________________
Cardiovascular (Check all that apply)
High Blood Pressure
High Cholesterol
Palpitations
Varicose Veins
Low Blood Pressure
Low Cholesterol
Irregular Heart Beat
Bruise Easily
Chest Pain/Pressure
History of Anemia
Edema (Legs/Hands/Eyes)
Do you have any cardiovascular diseases diagnosed by an MD?__________________________
Gastrointestinal (Check all that apply)
Daily Bowel Movement
Bowel Habits Changed
History of Candida
Laxative Use
Gallbladder Troubles
Nausea
Heartburn
Bloating
Constipation
Blood in Stool
History of Parasites
Ulcers
Mouth Tastes Bitter/Sour
Vomiting
Acid Reflux
History of Polyps
Diarrhea
Abdominal Pain
Hemorrhoids
Diabetes
Bad Breath
Stomachaches
Belching
Do you have any digestive diseases diagnosed by an MD?_______________________________
2
Urinary (Check all that apply)
Frequent Urination
History of Stones
Urgency to Urinate
Urinary Incontinence
Blood In Urine
Painful Urination
Recurrent Urinary Infections
How much water do you drink a day? (# of glasses)____________________________________
Do you have night urination? (# of times/night)________________________________________
Is your urine clear? (If no, please describe urine)_______________________________________
Do you have any urinary diseases diagnosed by an MD?________________________________
Musculoskeletal (Check all that apply)
Joint Pain/Stiffness Muscle Spasms/Cramps
Arthritis
Do you have any musculoskeletal disorders diagnosed by an MD?_________________________
Please mark any muscular soreness and/or pain on the picture model by using the
symbols that follow:
+++ = Sharp Stabbing
ooo = Pins & Needles/Tingling
vvv = Dull or Aching
lll = Numbness
--- = Trembling or Twitching
Severity of pain on a scale of
1-10? (1 is low)_____________
Is the pain fixed or does it
move?___________________
Neurological, Mental, Emotional (Check all that apply)
Numbness
Seizures
Migraines
Mental Disorders
Anxiety
Nervousness
Loss of Consciousness
Headaches
Bi-Polar Disorder
Mood Swings
Dizziness/Vertigo
Depression
Presently In Counseling
Insomnia
Considered/Attempted Suicide
Do you have any neurological, mental, or emotional disorders diagnosed by an MD?__________
______________________________________________________________________________
Skin & Hair (Check all that apply)
Dry Skin
Itchy Skin
Hair Loss
Had Shingles
Dermatitis/Warts
Brittle Hair
Skin Rashes
Early Gray
Psoriasis
Fungal Infections
Dry Scalp
Eczema
Facial Hair
Acne
Do you have any skin diseases diagnosed by an MD?___________________________________
3
Sensory (Check all that apply)
Eye Irritation
Color Blindness
Ear Congestion
Loss of Smell
Mouth Sores
Swollen Lymph Glands
Spots in Vision
Poor Hearing
Nasal Congestion
Sore Throat
Gum/Teeth Problems
TMJ
Night Blindness
Ear Ringing
Nasal Discharge
Dry Mouth & Throat
Lumps in Throat
History Ear Infections
Do you have any sensory diseases diagnosed by an MD?________________________________
History & Disorders (Check all that apply)
Male Patients Only
Infertility
Prostate Problems
Hepatitis(A, B, or C)___
Hernias
Female Patients Only
Irregular Periods
Painful Periods
Abnormal Bleeding
Herpes
Increased Sex Drive
Impotence
Herpes
Increased Sex Drive
Premature Ejaculation
HIV Positive
Decreased Sex Drive
Late Periods
Dark Menses
Yeast Infection
HIV Positive
Decreased Sex Drive
PMS
Clotty Menses
Vaginal Discharge
Hepatitis(A, B, or C)
History of Fibroids/Cysts
Age of First Period_______ Date of Last Period________ Date of Next Period_______
# of Child Births_________ Birth Control Type_________ # of Miscarriages_________
# Days in Cycle__________ # of Heavy Flow___________ # of Scanty Flow_________
Do you have any OB-GYN disease diagnosed by an MD?_____________________________
PLEASE MENTION ANY OTHER ISSUES YOU WISH TO DISCUSS BELOW:
4
For Caleb’s Use Only
Tongue Picture:
Pulse:
TW
ST
LI
UB
GB
SI
PC
SP
LU
K
LV
HT
Sm or <8
Lunulae
V. Large Lun
All fingers
Abdomen:
Finger Nails:
#Lunulae
Only thumbs
have Lunulae
No Lunulae
at all
Shape:
Ridges:
Color Pattern:
Other Objective Signs:
Summary:
TCM Diagnosis:
Treatment Plan:
Acupuncture:
Herbs:
5
Large or more
than 8
Pinkies have
small lunulae
Large lun
contr clear