Name
*
First Name
Last Name
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Date
*
MM
DD
YYYY
Date of Birth
*
MM
DD
YYYY
Gender
*
How did you hear about me?
*
Name
*
First Name
Last Name
Relation to you
*
Phone
*
(###)
###
####
Other healthcare providers you are currently seeing:
Main health problems (list your top 3):
*
When did the problem start?
*
What diagnosis, if any, have you received for this problem:
*
What treatments have you tried:
*
What makes it better:
*
What makes it worse:
*
What is your desired outcome from acupuncture:
*
Have you had acupuncture before? If yes, please describe your experience:
*
Do needles bother you? If yes, please explain:
*
Do you currently have or have you ever had the following (please check all that apply)
Other health conditions (please specify):
Please list all medications including herbs, vitamins and supplements:
*
List past injuries, hospitalizations, or surgeries with approximate dates:
*
Please list any allergies (food, medicines, environmental):
*
Do you frequently use any of the following (please check all that apply):
If yes to any of the above, please specify how often:
Describe your diet:
*
Any food restrictions (gluten free, etc):
Do you crave any particular foods (salty, sweet, sour, bitter):
Do you prefer hot or cold beverages:
Do you drink soft drinks? If yes, how many per/day:
Exercise – if yes, please describe:
Stress level (between 1- 10 - 1 indicating low and 10 indicating high):
*
Physical symptoms when stressed:
*
Does stress keep you up at night:
*
Sleep-- hours/night:
*
Feel rested in AM?:
*
Trouble falling asleep:
*
Trouble staying asleep:
*
Occupation:
*
Enjoy work?
*
Hobbies:
*
How’s your energy in general:
*
Do you feel you run more cold or hot or neutral in body temperature :
*
low appetite
0
1
2
3
4
hemorrhoids
0
1
2
3
4
mouth sores
0
1
2
3
4
bad breath
0
1
2
3
4
loose stools
0
1
2
3
4
bruise easily
0
1
2
3
4
belching
0
1
2
3
4
constipation
0
1
2
3
4
gas/bloating
0
1
2
3
4
ravenous appetite
0
1
2
3
4
gums bleeding
0
1
2
3
4
parasites
0
1
2
3
4
fatigue after eating
0
1
2
3
4
heartburn/acid reflux
0
1
2
3
4
thirsty
0
1
2
3
4
candida
0
1
2
3
4
allergies
0
1
2
3
4
dry skin
0
1
2
3
4
general weakness
0
1
2
3
4
shortness of breath
0
1
2
3
4
fatigue
0
1
2
3
4
nasal discharge
0
1
2
3
4
cough
0
1
2
3
4
catch colds easily
0
1
2
3
4
sinus congestion
0
1
2
3
4
dry nose/throat
0
1
2
3
4
tired after little exertion
0
1
2
3
4
sore, cold, weak knees
0
1
2
3
4
urinary incontinence
0
1
2
3
4
feel cold often
0
1
2
3
4
hair loss
0
1
2
3
4
joint pain
0
1
2
3
4
low back pain
0
1
2
3
4
hearing problems
0
1
2
3
4
swollen ankles
0
1
2
3
4
infertility
0
1
2
3
4
frequent urination
0
1
2
3
4
early morning diarrhea
0
1
2
3
4
poor memory
0
1
2
3
4
libido
low
normal
high
irritable
0
1
2
3
4
alternate diarrhea/constipation
0
1
2
3
4
muscle spasms/twitches
0
1
2
3
4
floaters
0
1
2
3
4
red eyes
0
1
2
3
4
tight muscles
0
1
2
3
4
numbness
0
1
2
3
4
ear ringing
0
1
2
3
4
migraines
0
1
2
3
4
tight feeling in chest
0
1
2
3
4
neck/shoulder tension
0
1
2
3
4
dry/irritated eyes
0
1
2
3
4
anger easily
0
1
2
3
4
headaches
0
1
2
3
4
feel heart beating
0
1
2
3
4
anxiety
0
1
2
3
4
restlessness
0
1
2
3
4
insomnia
0
1
2
3
4
chest pain
0
1
2
3
4
palpitations
0
1
2
3
4
sores on tip of tongue
0
1
2
3
4
disturbing dreams
0
1
2
3
4
dizzy upon standing
0
1
2
3
4
night sweats
0
1
2
3
4
foggy thinking
0
1
2
3
4
heat in palms or soles
0
1
2
3
4
flushed face
0
1
2
3
4
cloudy urine
0
1
2
3
4
nausea
0
1
2
3
4
Urination (check all that apply)
Bowel movements (check all that apply)
How often do you have bowel movements?
*
Are you currently pregnant:
Please list your # of pregnancies, # of live births, and # of miscarriages:
How old where you when you had your first period:
Have you experienced menopause? If yes, what age:
If you are perimenopausal, please describe your symptoms:
Vaginal discharge? If yes, what color:
Itch/Burn/pain/foul odor:
Is your period regular?
When was the first day of your last cycle:
Typical length of cycle (start of one period to start of next):
Average # of days in flow
Flow – light, normal, or heavy:
Color – pale, normal, dark, bright red, brown, purple?:
Blood clots? If so, how big:
Cramps? How Severe?
Type of pain with cramping – please indicate – sharp, dull, constant, intermittent
Do you experience premenstrual symptoms before your cycle? If yes, please describe your symptoms (breast swelling, water retention, mood swings, depression, headaches/migraines, diarrhea, constipation, hot flashes, food cravings, etc)
Please indicate all that apply:
Other health concerns:
Date
*
MM
DD
YYYY
