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Intake Form
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Intake Form
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Step
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Personal Information
Name
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Email
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Today's Date
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Address
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Texas
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Zip Code
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Emergency Contact Information
Name
*
First
Last
Phone
*
Relationship
*
Next
What brings you here?
Referred By
First
Last
Seeking treatment for the following health concerns:
Onset date
Has any treatment helped this (these) conditions(s)? Please list:
What makes this condition worse?
Have you had acupuncture before?
*
Select
No
Yes
Please list any pharmaceutical drugs or herbs that you are currently taking:
Please list any surgeries, accidents, or injuries that you have had (month/year):
Next
Health Information
Check all that apply.
General
Chills
Fever
Low energy/fatigue
Night sweats
Spontaneous sweating
Aversion to heat
Aversion to cold
Recent weight loss
Recent weight gain
Susceptible to colds/flu
Eyes & Ears
Floaters
Blurry vision
Pain behind eyes
Inflamed eyes/redness
Tearing
Cataract
Glaucoma
Infection
Earache
Ringing in ears
Discharge from ear
Other
Eyes & Ears - explain other
Headache
Headaches
Migraines
Tight band headache
Sharp headache
Dull headache
Headache with nausea
Other
Headaches - which region of the head?
forehead, sides, etc.
Headaches - explain other
Respiratory
Asthma
Difficulty breathing
Difficulty exhaling
Tightness in chest
Phlegm in lungs
Sensation of something stuck in throat
Coughing up blood
Hoarseness
Loss of voice
Pneumonia
Current history of pneumonia
Hay fever/allergies
Sinus congestion
Nasal mucus
Loss of sense of smell
Other
Phlegm in lungs - what color?
Phlegm in lungs - able to bring it up?
Select
No
Yes
Nasal mucus - what color?
Respiratory - explain other
Dental health - any of the following a current, or past, issue?
Sore & bleeding gums
Cavities
Swelling
Pain
TMJ
Root canals
Implants or dentures
Hot or cold sensitivity
Braces
Last dental visit
Overall dental health
Select
Not Great
Fair
Good
Great
Cardiovascular
Chest pain/angina
Palpitations
High blood pressure
Low blood pressure
Irregular heartbeat
Hypochondriac pain (pain under ribs)
Cold hands or feet
Poor circulation
Ankle swelling
History of heart attack, heart failure
Other
Cardiovascular - explain other
Gastrointestinal
Difficulty swallowing
Bloating
Belching
Gas
Abdominal distension
Constipation
Diarrhea
Burning sensation
Blood in stool
Black stool
Undigested food in stool
Candida/yeast infections
Irritable bowel syndrome
Gout
Hemorrhoids
No appetite
Insatiable appetite
Nausea
Acid regurgitation/heartburn
Thirst
Prefer hot/cold drinks
Other
Gastrointestinal - Is thirst quenched by drinking?
Select
No
Yes
Gastrointestinal - explain other
Uro-Genital: Urination
Profuse amount
Urgent/bladder control problem
Scanty amount
Cloudy urine
Frequent urination
Burning sensation
Urine with blood
Current urinary tract infection
History of urinary tract infections
Uro-Genital: Other
Genital pain/swelling
Genital sores
Impotence
Seminal emissions
Low sexual energy
Other
Uro-Genital: Other - explain other
Pain
Soreness
Dull
Sharp
Inflamed or swollen
Better with cold
Better with heat
Worse in damp weather
Repetitive stress injury
Result of an accident
Pain - where does the pain radiate to?
Pain - what type of accident?
Neurological
Sensation of numbness
Tingling sensation
Sensation of pins and needles
Tremors
Drowsiness
Vertigo
Paralysis
Stroke
Seizure
Loss of balance
Dizziness
Other
Neurological - Location for any of these symptoms
Neurological - explain other
Skin/Hair
Acne
Eczema/psoriasis
Oily skin
Bruise easily
Dark circles/bags under eyes
Sores/lumps
Brittle nails
Dry hair
Hair loss
Skin/Hair - Where are the sores/lumps located?
Emotional
Anxiety
Anger
Depression
Difficulty concentrating
Fear
Nightmares
Irritable
Insomnia
Trouble going to sleep
Interrupted sleep
Other
Emotional - What time do you wake up?
Emotional - explain other
Next
Women
Age at onset of menses
Length of cycle
(ex., every 28 days)
Number of pregnancies
Blood quality
Dark purple
Bright red
Pale/pink
Clots
Scanty
Heavy
Do you experience
Premenstrual tension
Constipation or diarrhea before or during menses
Feeling of fatigue before or during menses
Pre/post menopausal
History of yeast infections/candida
Sores on genitalia
Painful periods
Fibroids
Ovarian cysts
Endometriosis
Abnormal PAP smear
Uterine prolapse
Hysterectomy
C-section
Breast tenderness
Breast lumps
Other
Experience: explain other
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