Today’s Date ____/____/____

New Patient Intake Form

_________________________________________________ ____/____/____ ________

First Name (Print) Last Name Birth Date Age

_____________________________________ _________________ ______ _________

Address City State Zip

_______________________ _______________________ ______ ______ _____

Phone (home) Phone (work) Height Weight Sex

____________________________________________________________________

How did you hear about us? (Doctor’s name, Nurse , Drs office staff, website, flyer, postcard etc)

If you were referred by your doctor, may contact him/her to thank them? ______________________

____________________________________________ ____________________________

Emergency Contact Name and Phone Email Address

Have you had acupuncture before?_______ For what?______________________________________

Chinese Herbal Medicine?______ Name of acupuncturist/herbalist ___________________________

Are you currently under the care of a physician? _______ For what?____________________________

Physician’s Name and Phone ___________________________________________________________

Below, describe all of your complaints on the left side of the page starting with your primary reason for today’s visit, then list how long you have had them and how you are treating them directly opposite on the right side. Be sure to mention any drugs, vitamin supplements, or other medicinal substances you are taking.

Complaints:

How Long?

Treatment:

Brief Health History (list major diseases, surgeries, etc.):

How many times per year do you get a cold or the flu? ______

Diet (summarize how you eat; list any special diet such as high protein, raw food, etc.):

Family Medical History:

Emotions:

q Normal q Problem

q Depression q Sadness q Panic attack q Sensitive q Worries q Overly excited

q Anger q Anxiety

Describe: _____________________________________________________________________

_____________________________________________________________________________

Energy:

q Normal q Problem

q Low q Up and down q Exhausted q Hyperactive q Nervous energy q Abundant

Describe: _____________________________________________________________________

_____________________________________________________________________________

Sleep Pattern:

q Normal q Insomnia

Falling Asleep: q Sometimes Difficult q Always difficult

q Sometimes very difficult q Always very difficult

q Sleep in daytime q Take naps

Waking up: ___ Times per night q Wake up too early

q Wake up at night and cannot go back to sleep again

Sleep Quality:

q Deep q Light q Bad

q Many dreams q Bad dreams q Grinding teeth q Talking in sleep q Other

Describe: _____________________________________________________________________

_____________________________________________________________________________

Temperature:

q Normal q Abnormal

q Feel cold easily q Cold Hands q Cold feet q Alternating hot and cold

q Feel hot easily q Hot flash q Sensitive to weather changes

Describe: _____________________________________________________________________

_____________________________________________________________________________

Sweating:

q Normal q Abnormal

q Too easily q Too much q Difficult q Too little q Night Sweats q Other

Describe: _____________________________________________________________________

_____________________________________________________________________________

Sensitivity and Allergies:

q No q Yes

q Cold q Hot q Dampness q Light q Noise

q Airborne particles q Food q Drugs q Other

Describe: _____________________________________________________________________

_____________________________________________________________________________

Appetite and Digestion:

q Normal q Abnormal

q Rapid Hungering q Poor appetite q Nausea q Anorexia q Bloating q Gas

q Hungry, but no desire to eat q Other

Describe: _____________________________________________________________________

_____________________________________________________________________________

Bowel Movement:

q Normal q Abnormal Time of day: __________

q Constipation q Diarrhea q Loose q Watery q Incomplete q Hard and Dry

q Strong Smell q With mucous q With blood q Other

Describe: _____________________________________________________________________
_____________________________________________________________________________

Body Weight:

q Normal q Overweight q Underweight

If overweight:

How many pounds would you like to lose? _____

How many years ago did you first start to gain weight? _____

Are you following a weight control program at this time? _____

Describe: _____________________________________________________________________

_____________________________________________________________________________

Drinking:

q Normal q Abnormal

q Thirsty q Dry Mouth q Drink a lot q Dry mouth but no desire to drink

q Not thirsty but drink a lot anyway

Describe: _____________________________________________________________________

_____________________________________________________________________________

Urination:

q Normal q Abnormal

q Frequent q Urgent q Burning q Painful q Cloudy q Dark Color

q Foul smell q Bloody q Difficult q Retention

Number of times per day_____ Number of times per night_____ Other____________

Describe: _____________________________________________________________________

_____________________________________________________________________________

Lifestyle:

q Alcohol q Tobacco q Marijuana q Drugs q Occupational Hazards

Regular exercise: Type____________ Frequency___________

Type____________ Frequency___________

Menstrual History

Age at which Menses Began _____

Age at which it stopped _____

Are your periods painful? q Yes q No

How many days does the pain last? _____

How many days do you normally bleed? _____

How heavy is the bleeding? qLight qNormal q Heavy

What color is the blood? qLight red qRed qDark Red

qBrown qBlack

Is there clotting? qYes qNo

Do you have premenstrual tension? qYes qNo

Does your face break out before or during your period? qYes qNo

Do your breasts become tender premenstrually? qYes qNo

Do you retain water during your period? qYes qNo

Do you bleed or spot between periods? qYes qNo

Are your menstrual cycles spaced irregularly? qYes qNo

How many days are there from one period to the next? _______

Date of last menstrual period _______________

Number Years

How many pregnancies have you had? ______ ______________

How many children do you have? ______ ______________

How many abortions have you had? ______ ______________

How many miscarriages have you had? ______ ______________

How many times has a D&C been performed? ______ __________

Complications? __________________________________________

Have you ever had an abnormal pap smear? qYes qNo

Have you ever had a cervical biopsy, operation,

cauterization or conization? qYes qNo

Have you ever had a venereal disease? qYes qNo

Do you get yeast infections regularly? qYes qNo

Have you ever been

diagnosed with a chlamydial infection? qYes qNo

Do you have chronic vaginal discharge? qYes qNo

Do you have any sores on your genitalia? qYes qNo

Have you ever had pelvic inflammatory disease? qYes qNo

Were you treated for it? qYes qNo

How? ______________________________________________
_______________________________________________________

Date of last Pap smear __________________________

Have you ever been diagnosed

with uterine fibroids or polyps? qYes qNo

Have you ever been diagnosed with endometriosis? qYes qNo

Have you been diagnosed with pelvic adhesions? qYes qNo

Have you been diagnosed

with any pelvic abnormalities? qYes qNo

Have you taken any medications other than contraceptives

for gynecological conditions?

Medicine Reason How long

_____________________ ____________________ __________

_____________________ ____________________ __________

_____________________ ____________________ __________

_____________________ ____________________ __________

_____________________ ____________________ __________

_____________________ ____________________ __________

_____________________ ____________________ __________

_____________________ ____________________ __________

_____________________ ____________________ __________

Have your cycles changed since they began? qYes qNo

How? __________________________________________________

Do you ovulate on your own? qYes qNo

On what day of your cycle? ___________________________

Do your breasts get tender at/during ovulation? qYes qNo

Do you get premenstrual low back pain? qYes qNo

Do your bowel movements become loose at the beginning of your period? qYes qNo

5

Fertility History

How long have you been trying to conceive?_________________

Is there a history of infertility in your family? qYes qNo

Describe: _________________________________________

Have you had fertility treatments? qYes qNo

If yes, when and where? ______________________

By whom? _________________________________

What types? _______________________________

Have you taken medication to help you ovulate? qYes qNo

When? _________________ How long? ______________

Have your fallopian tubes been evaluated medically? qYes qNo

What were the results? ______________________________

Have you had any tubal operations? qYes qNo

Have you had any hormone laboratory tests performed? qYes qNo

What were the results? _____________________________
Do you have a single partner

with whom you have been trying to conceive? qYes qNo

How long have you been married or living together?________

Has he had a fertility workup? qYes qNo

What were the results? ______________________________

Is your partner supportive of your wish to conceive? qYes qNo

Have you taken oral contraceptives? qYes qNo

When?__________________ How long?__________________

Have you ever had an IUD? qYes qNo

When? __________________ How long?__________________

Have you ever taken DepoProvera? qYes qNo

When? __________________ How long? _________________

Have you had a diagnosis relating to infertility? qYes qNo

What was it? ________________________________________
How is your sexual energy? qLow qNormal qHigh

Are you experiencing any sexual problems? qYes qNo

Does your partner experience any

sexual dysfunction? qYes qNo

Do you douche regularly? qYes qNo

With what? _____________________________

Do you use vaginal lubricants? qYes qNo

Are you more than 20% over your ideal body weight? qYes qNo

Are you more than 20% below your ideal body weight? qYes qNo

Do you have a stressful occupation? qYes qNo

Do you exercise regularly? qYes qNo

Do you have excessive facial hair? qYes qNo

Do you have excessively oily skin? qYes qNo

Have you experienced excessive loss of head hair? qYes qNo

Have you noticed discharge from your nipples? qYes qNo

Was your mother exposed to diethylstilbestrol

(DES) when she was pregnant with you? qYes qNo

Have you been exposed to any

known environmental toxins or hormones? qYes qNo

Are you presently taking steroids? qYes qNo