Intake Form

Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Primary Phone

Cell Phone

Emergency Phone

Emergency Contact

Email Address

Place of Birth

Date of Birth

Time of Birth *if known

Chinese Astrology Year

Month

Hour

Profession

How Long?

Height

Weight

Current Age

Single / Married / Divorced

Children - Ages

Have you been treated with acupuncture before?

Who?

For What?

Results

How did you hear about us?

What has brought you here?

How long has this been going on, and how did it begin?

Diagnosis?

What kinds of treatment have you tried?

Does anything make it better?

Worse?

Current Medications & Supplements

Part Two

Family Medical History (General Health)

Mother's side

Father's side

Siblings

If above deceased cause of death:

Childhood Health (Physical)

(Emotional)

Location of upbringing:

Current emotional health:

Current predominant emotion:

Current Quality of Life:

Current Relationship/Quality:

Is there much stress in your life?

What?

Hobbies and Recreational habits:

Favorite time of year?

Least favorite time of year?

Do you have a regular exercise program?

Please describe:

Travel abroad during the past year?

Where?

Do you feel like you have a good appetite?

Good eating habits?

Please describe your average daily diet:

Morning

Afternoon

Night

Portion of raw food

To cooked food

Do you get cravings?

What/When?

Preferred Tastes:

Sour

Bitter

Sweet

Spicy

Salty

How many packs of cigarettes do you smoke a day?

How much coffee, tea, or cola do you drink per week?

How much alcohol do you drink per week?

Please describe any recreational drug use (this info is strictly confidential):

Have you ever abstained or "quit" anything?

Do you have any nervous habits?

What factors in your life seem destructive to your daily health?

Age at First Menses

Days Between Menses

First Date of Last Menses

Last Menses Heavy or Light?

Number of Pregnancies

Number of Births

Have you ever taken birth control? What type? How long?

Are you currently taking birth control? What type? How Long?

Date of Last Pap Smear

Are there any other problems, conditions, or observations you would like to discuss?

What are your goals for health and life?

Other Concerns?

I recognize that the major factor in my health is myself, that none can do the healing for me, and that my participation in my own care is key. That without following the recommendations, taking herbs, doing the practices, shifting the lifestyle, etc little can be expected and no promise of result is offered.

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