Clinic Intake Form

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Patient*

First Last

Patient Representative

First Last

Patient Email*

Today's Date*

Occupation*

Patient Home Phone

Patient Cell Phone*

Patient Work Phone

Date of Birth*

Age*

Height*

Weight*

Marital Status*

Gender*

What gender were you at birth?*

Patient Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact’s Name*

First Last

Emergency Contact’s Phone*

Physician’s Name*

First Last

Physician’s Phone*

Physician’s Diagnosis

Allergies (environmental, food, medications)

Have you ever had acupuncture before?*

Yes

No

What is the problem that brought you here today?*

Are you experiencing pain right now?*

Yes

No

When did this problem first appear?*

Does the problem ever move?*

For example, pain or spasms that occur in different joints or muscles at different times

Yes

No

Is it constant or does it come and go?*

Has there been anything that has ever been able to change your problem in any way?*

Yes

No

Please describe what changed your problem

Do you ever experience dizziness?*

Yes

No

Do you have a history of chronic pain?*

Yes

No

What number best describes your pain?

What is the frequency of the pain?

Continuous

Intermittent

Is your illness affected by seasonal changes? Please describe.

What makes your pain better? Please check all that apply.*

Heat

Cold

Pressure

Massage

Movement

Rest

Other

Please choose the areas of pain

Are there other problems you would like addressed?

Have you eaten today?*

Yes

No

What time was your last meal?

:

Hours per night that you sleep*

Do you wake up frequently?*

Yes

No

When do you wake up frequently?

Do you have trouble falling to sleep?*

Yes

No

Do you wake up early and cant fall back to sleep?*

Yes

No

Have you ever smoked?*

Yes

No

Do you still smoke?*

Yes

No

When did you quit smoking cigarettes?

How many cigarettes do you smoke daily?

Do you drink alcohol?*

Yes

No

How many glasses of alcohol per week?

Do you regularly experience abdominal pain?*

Yes

No

What makes your abdominal pain better? Please check all that apply.

Heat

Cold

Eating

Not Eating

Movement

Rest

Massage

Other

Do you have any emotional difficulties? Please check all that apply.*

No

Anxiety

Depression

Mania

Mood Swings

Seasonal Affective Disorder

How would you rate your ability to concentrate/maintain focused thinking, and have clarity of thought?*

Good

Excellent

Fair

Poor

How would you rate your appetite?*

Excessive

Good

Fair

Poor

Do you crave sweets?*

Yes

No

Do you crave other foods? What type?

Describe your bowel habits*

Regular

Constipation

Diarrhea

How many times a day do you move your bowels?*

Does the diarrhea occur early in the morning when you first wake up?

Yes

No

How many episodes of diarrhea do you have per day?

After constipation, do you feel better or worse after moving your bowels?

Better

Worse

How many days pass before you move your bowels after constipation?

How many times a day do you urinate per day?*

Color of Urine*

Clear

Pale Yellow

Dark Yellow

Volume of Urine*

Scant

Normal

Abundant

Are you often thirsty?*

Yes

No

What temperature do you prefer your drinks? Please check one choice.*

Do you often feel cold?*

Yes

No

Where do you feel cold in your body?

Have you had your lymph nodes removed?*

Yes

No

Please detail your lymph node removal

Do you have any infectious diseases?*

Yes

No

Please detail infectious diseases

Describe the degree to which you sweat*

Do you sweat at night?*

Yes

No

Do you exercise?*

Yes

No

How often do you exercise?

What type of exercise?

How would you rate your energy level?*

Excellent

Good

Fair

Poor

Do you have a history of drug abuse?*

Yes

No

Number of vegetable portions eaten daily*

Please enter a number from 1 to 12.

Number of meat product portions eaten daily*

Please enter a number from 1 to 12.

Number of whole grain product portions eaten daily*

Please enter a number from 1 to 12.

Number of caffeine containing products eaten daily*

Please enter a number from 1 to 12.

Please list any medications, vitamin, and supplements you take currently*

Please include the Date plus Dosage, Route, Frequency

Have you had any surgeries/hospitalization? If yes, what type of surgery/procedure and when did you have it done?

Your History of Significant Illness*

Please include all past accidents, childhood illnesses, and the date that they occurred.

Sibling(s) History of Significant Illness*

Please include all past accidents, childhood illnesses, and the date that they occurred.

Mother's History of Significant Illness*

Father's History of Significant Illness*

Maternal Grandmother/Grandfather History of Significant Illness*

Paternal Grandmother/Grandfather History of Significant Illness*

Women Only

Is there a chance that you could be pregnant?*

Yes

No

Describe your menstrual cycles*

Regular

Irregular

Early

Late

How many days is your cycle from 1st day of bleeding to last day before next period?*

Please enter a number from 1 to 12.

Age of Menarche (first menstrual cycle):*

Please enter a number from 1 to 24.

How many days does your period last?*

Please enter a number from 1 to 12.

Describe your menstrual flow*

Heavy

Normal

Light

Is the blood*

Normal

Purplish

Dark

Light

Does your menstrual blood contain clots?*

Yes

No

What color are the clots?*

Bright Red

Dark in Color

Are they larger than a quarter?*

Yes

No

Do you have vaginal discharge?*

Clear

White and Thin

Yellow and Thick

Do you have itching or soreness of the vagina?*

Yes

No

If you generally experience mood swings, use the choices below to describe how they are around the time of your menses.*

Better

Worse

Same

Not Applicable

Do you have symptoms that only appear prior to your period?*

Yes

No

What are your symptoms?

Select All

Sore Breasts

Mood Swings

Headaches

Bloating

Anger

Sadness

Other

Number of pregnancies

Number of abortions

Number of miscarriages

Signature*

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