One Medicine Integrative Health
Brie Wieselman, L.Ac, MTCM
740 Front St, Suite 318, Santa Cruz CA, 95060
Phone (844) 334-6179 Fax (866) 643-8029
Dear Client,
Welcome!, And thank you for choosing One Medicine.
HOW THE PROCESS WORKS:
STEP 1:
Fill out the new client paperwork. The single most important criteria for us to help you with your health
is a comprehensive and detailed health history. Please answer the accompanying questions with as
much detail as possible. It is important for us to know everything about you and your health. Even
when you feel the questions may not be directly relevant to your situation, please do your best to
answer them.
It takes tremendous time and energy for us to help a complicated health case. Our consultation time
is very limited therefore the case review process is very important. Please schedule the appropriate
amount of time (1-2 hours) needed to complete the questions. Once you’re finished, please email it to
Brie@one-medicine.net or fax it to: (831) 471-8064.
STEP 2:
During your initial consultation Brie will review your health history and make recommendations for lab
tests that are appropriate for your specific health issues.
STEP 3:
Once you have completed your lab tests, Brie will explain the meaning of your test results to you in a
follow up consultation. They will create an individualized therapeutic program for you including diet
changes, nutritional supplements, and exercise, lifestyle and stress management advice, and
potentially acupuncture therapy.
STEP 4:
Subsequent consults are scheduled to monitor your progress. Brie will also design an on-going
wellness program to be reviewed and updated with our staff at no charge every six months.
We invite you to contact us via email should you have any questions during the course of our relationship.
Please email: ClientCare@OMintegrativehealth.com
We look forward to assisting you in achieving your current wellness goals, and to guiding you in maintaining
wellness throughout your life.
In health,
Brie Wieselman and the team at One Medicine Integrative Health
One Medicine Integrative Health
Brie Wieselman, L.Ac, MTCM
New Client Paperwork
Name:
Date:
Address:
Country:
City:
State:
Zip/Postal Code:
Skype ID (required for Int’l):
Home Phone:
E-mail:
Cell Phone:
Please mark your preference for occasional follow up communication from our office: _____Email _____Phone
Age:
Birth date:
Sex: M
F
Occupation:
Employer:
Spouse’s Name:
Occupation:
Status: M S W D
Person responsible for this account:
No. Children:
Years Employed:
Employer:
Referred by:
What is your major complaint?
Other complaints?
What are your overall health goals once your complaints are resolved?
How long has it been since you really felt good?
List all diagnoses given to you in a timeline sequence and your personal opinions about them.
OMIntegrativehealth.com
2
What's your opinion on what has happened to your health?
List any treatments, medications or supplements that have improved your health.
Please answer all questions frankly, to the best of your knowledge. All information is confidential.
Weight ______ Height _______
1. Are you presently taking any medications, nutritional supplements or vitamins? If YES please list Brand
names and dosage per day please list (attach sheet if necessary)_____________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. In the past, have you used birth control pills and/or antibiotics?______________________________________
a. For how long?________________________________________________________________________________
3. If you have fillings, please list material(s) used:___________________________________________________
4. Do you presently, or have you ever had any of these conditions? (circle)
OMIntegrativehealth.com
One Medicine Integrative Health
Brie Wieselman, L.Ac, MTCM
Anemia
Frequent Headaches
Skin condition
Arthritis
Heartburn
Thyroid condition
Asthma
High blood pressure
Unexplained weight change
Chest pains
High cholesterol
Chronic cold/flu symptoms
Hypoglycemia
Chronic fatigue
Kidney problems
Depression
Liver problems
Diabetes
Osteoporosis
5. How much sleep do you get each night on average?_________________________________________________
6. Do you have any food allergies, sensitivities or restrictions?__________________________________________
____________________________________________________________________________________
7. Do you smoke, drink alcohol or use recreational drugs?_____________________________________________
a. How much, how often?________________________________________________________________________
b. How often do you drink caffeinated beverages?____________________________________________________
8. Please list foods you tend to overeat or crave (Sweets, breads, fatty foods, meats, milk, etc.):_________________
______________________________________________________________________________________________
9. Are there foods that you eat on a daily basis, almost daily basis?______________________________________
______________________________________________________________________________________________
a. Do you “miss” these foods if you do not eat them?__________________________________________________
b. Please list the foods you've eaten over the last 2 days?_______________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
10. Write briefly about your weight gain/loss history:_________________________________________________
____________________________________________________________________________________
a. What do you feel triggered your weight fluctuation? (circle) heredity
OMIntegrativehealth.com
4
stress
eating habits
boredom
b. Was your weight gain/loss: (circle) sudden
gradual
problem since childhood
11. Please list close relatives that have diabetes, heart disease or obesity:_________________________________
______________________________________________________________________________________________
12. What methods have you tried to lose/gain weight_________________________________________________
____________________________________________________________________________________
13. How is your energy level?_____________________________________________________________________
a. Are there times in the day that you feel best?_______________________worst?_________________________
14. Are you happy in your life right now?___________________________________________________________
15. What are your main sources of stress___________________________________________________________
______________________________________________________________________________________________
16. How do you deal with your
stress?______________________________________________________________________________________
______________________________________________________________________________________
17. Please answer the following questions Yes or No:
a. If I’m feeling down, a snack makes me feel better. Yes_____ No_____
b. I sometimes have a hard time going to sleep without a bedtime snack. Yes_____ No _____
c. I get tired and/or hungry in the mid-afternoon. Yes_____ No_____
d. I get a sleepy, almost “drugged” feeling after eating a meal containing bread, pasta or dessert. Yes_____ No _____
e. Now and then I think I am a secret eater. Yes _____ No_____
f. At a restaurant, I almost always eat too much bread before the meal is served. Yes_____ No_____
g. I have difficulty concentrating, or frequent fuzzy or spacey thinking patterns. Yes_____ No_____
h. I experience cravings for sugar, breads, pasta and baked goods. Yes _____ No_____
i. I feel shaky if I don’t eat on time or if I don’t snack. Yes_____ No_____
j. I often find myself irritable or angry. Yes_____ No_____
18. Check off any of the following that have applied to you within the last 30 days:
_____Do you feel nauseous?
_____Do you have abdominal/intestinal pain?
OMIntegrativehealth.com
One Medicine Integrative Health
Brie Wieselman, L.Ac, MTCM
_____Do you have bloating?
_____Do you get bloated after meals?
_____Do you get heartburn?
_____Do you have diarrhea?
_____Do you have constipation?
_____Do you travel outside of the U.S.?
_____Do you have gas?
_____Are your stools compact/hard to pass?
_____Do you belch following meals?
_____Do you have gurgles in your stomach?
_____Do your bowel movements alternate between
constipation and diarrhea?
For each of the above checked symptoms, please answer the following:
a. How long does it occur after they eat?_________________________________________________________
__________________________________________________________________________________________
b. How often does it occur in a day and over the period of a month?____________________________________
__________________________________________________________________________________________
c. Are there any other symptoms, pain, or feelings you experience during or after you eat that were not
addressed here?_____________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
24. In your estimation, how physically fit are you right now?
Unfit_____ Below average_____ Average _____ Above average_____ Very fit_____
25. How often do you exercise? ___________________________________________________________________
a. What is your regimen?________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
26. If you do not currently exercise, what types of exercise have you enjoyed doing in the past? ______________
_____________________________________________________________________________________________
OMIntegrativehealth.com
6
28. Surgeries, starting with most recent:___________________________________________________________
29. Hospitalizations:____________________________________________________________________________
30. Briefly describe where you have lived since childhood:_____________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
31. What is your heritage? (Irish, German, Spanish, etc.) ___________________________________________
32. Circle “Now” or “Past” for only those items with which you identify. Ignore anything that does not apply to
you.
Is your life:
Now Past Satisfactory
Now Past Boring
Now Past Demanding
Now Past Unsatisfactory
Do you worry over:
Now Past Home life
Now Past Marriage
Now Past Children
Now Past Job
Now Past Income
Now Past Money problems
Do you often:
Now Past
Now Past
Do you often:
Now Past
Now Past
Now Past
Now Past
Now Past
Now Past
Have you:
Now Past
Now Past
Feel depressed
Have anxiety
Have irrational fears
Feel upset
Feel things go wrong
Feel shy
Cry
Feel inferior
Seriously considered suicide
Attempted suicide
33. Women please answer the following questions.
a. Form of birth control ___________
b. # of children __________________
c. # of pregnancies _______________
d. Age of first period _____________
e. Date - last menstrual cycle ______
f. Length of cycle __________ days
g. Interval of time between cycles_______________________days
h. Any recent changes in normal menstrual flow (e.g., heavier, large clots, scanty) ____________________
__________________________________________________________________________________________
OMIntegrativehealth.com
One Medicine Integrative Health
Brie Wieselman, L.Ac, MTCM
i. Do you persistently experience any of these symptoms within three days to two weeks prior to
menstruation? Please check Yes or No.
[A]
1. Anxious, irritable or restless Yes_____ No _____
2. Numbness, tingling in hands and feet Yes_____ No _____
3. Easy to anger, resentful Yes_____ No _____
4. Aggressive or hostile toward family/friends Yes_____ No _____
[B]
5. Abdominal bloating, feeling swollen (e.g., feet) Yes_____ No _____
6. Temporary weight gain Yes_____ No _____
7. Breast tenderness, swelling Yes_____ No _____
8. Appearance of breast lumps Yes_____ No _____
9. Discharge from nipples Yes_____ No _____
10. Nausea and/or vomiting Yes_____ No _____
11. Diarrhea or constipation Yes_____ No _____
12. Aches and pains (back, joints, etc.) Yes_____ No _____
[C ]
13. Craving for sweets Yes_____ No _____
14. Increased appetite or binge eating Yes_____ No _____
15. Headaches Yes_____ No _____
16. Being easily overwhelmed, shaky or clumsy Yes_____ No _____
17. Heart pounding Yes_____ No _____
18. Dizziness or fainting Yes_____ No _____
[D]
19. Confused and forgetful to the point that work suffers Yes_____ No _____
20. Overwhelmed with feelings of sadness and worthlessness Yes_____ No _____
21. Difficulty sleeping or falling asleep Yes_____ No ____
OMIntegrativehealth.com
8
22. Engaging in self-destructive behavior Yes_____ No _____
j. Do you experience any of these symptoms during your period? Please check Yes or No.
1. Cramping in lower abdomen or pelvic area Yes_____ No _____
2. Lower abdominal pain is sharp and/or dull or intermittent Yes_____ No _____
3. Bloating and sense of abdominal fullness Yes_____ No _____
4. Diarrhea or constipation Yes_____ No _____
5. Nausea and/or vomiting Yes_____ No _____
6. Low back and/or legs ache Yes_____ No _____
7. Headaches Yes_____ No _____
8. Unusual fatigue (take naps) resulting in missed work Yes_____ No _____
9. Painful and/or swollen breasts Yes_____ No _____
10. Scanty blood flow Yes_____ No _____
k. Do you experience these symptoms in general? Please check Yes or No.
1. Painful or difficult sexual intercourse Yes_____ No _____
2. Low abdominal, back and vaginal pain throughout the month Yes_____ No _____
3. Pelvic pressure or pain while sitting down or standing up, relieved by lying down Yes_____ No _____
4. Vaginal bleeding other than during your period Yes_____ No _____
5. Painful bowel movements Yes_____ No _____
6. Difficult (straining) urination Yes_____ No _____
7. Abnormal vaginal discharge Yes_____ No _____
8. Offensive vaginal discharge Yes_____ No _____
9. Vaginal itching or burning with or without intercourse Yes_____ No _____
10. Pain during periods is getting progressively worse Yes_____ No _____
11. Profuse or prolonged menstrual bleeding Yes_____ No _____
12. Unable to get pregnant Yes_____ No _____
l. Please explain in detail any relevant history ___________________________________________________
__________________________________________________________________________________________
OMIntegrativehealth.com
One Medicine Integrative Health
Brie Wieselman, L.Ac, MTCM
Personal Opinion Questions
**Please do not answer "I don't know" to any of these questions**
1. If so, why do you think healthcare practitioners have failed in your
case?______________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
2. What do you consider a realistic window of time to see changes in your health after speaking with
us?___________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
3. Are you prepared to pay for the laboratory testing, consulting fees and nutritional supplements that may
be required to successfully manage your condition? _____________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
4. On a scale of 1-10, how committed are you to recovering your health?____________________________
______________________________________________________________________________________
5. What obstacles or beliefs, if any, stand in the way of you recovering your health?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
6. Are there emotional or psychological issues that may be contributing to your health problems? If so,
please briefly explain. ____________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
OMIntegrativehealth.com
10
7. Do you enjoy your work? Do you believe your work contributes to your health problems?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
8. Where else do you find support? Friends? Family? Nature? Church or Religion?
______________________________________________________________________________________
______________________________________________________________________________________
9. How did you feel about answering all of these questions and the case review process?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
OMIntegrativehealth.com