Today’s Date ____/____/

New Patient Intake Form

_________________________________________________ ____/____/____ ________

First Name (Print) Last Name Birth Date Birth Time

_________________________ ____________

Birth Location (City, State) Age

_____________________________ __________________ _________

Current Address City Zip Code

_______________________ _______________________

Phone (home) Phone (work) or cell phone

____________________________________________________________________

How did you hear about us? ( personal referral, website, flyer, Heartwood materials etc)

Email Address _______________________________________________________________

Would you like to receive a monthly health newsletter (via email)? ___________ (yes or no)

Would you like a super-bill to submit to insurance or for flex account reimbursement _______ (yes or no)

Have you had acupuncture before?_______ For what?______________________________________

Taken Chinese Herbal Medicine, Homeopathic, Flower Essence?_____(Yor N) What?_______________

Are you currently under the care of a M.D.? _______ For what?____________ How Long?__________

Result of treatment: ____________________________________________________________________

What are the three primary reasons for your visit today?

1. How long ? ___________Severity (0-10 10 worse)_______

2. How long ? ___________Severity (0-10 10 worse)_______

3 How long ? ___________Severity (0-10 10 worse)_______

Treatment Expectations and Commitment:

For each of your primary reasons for your visit today, what are your treatment expectations using acupuncture, NAET and/or holistic supplements? (the number of treatments a client will require will depend on the nature and severity of the condition- assume 6 weeks of at least 1x week treatment minimum) Please answer in terms of symptom relief and number of treatments.

1.

2.

3

Are you willing to take herbal or other holistic supplements (like digestive enzymes, homeopathic) for at least six weeks as recommended? ____________ (Yes or No)

Below, please list any pharmaceutical drugs, vitamin supplements, herbs, or other medicinal substances you are taking on a regular, daily basis

Medications:

How Long?

Treatment Goal:

Brief Health History:

Any major diseases, STD’s, surgeries, broken bones, accidents that resulted in injury etc.?

Please List:

Pain? _________________________ How Long?__________ Weather/Diet Related?________

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

Does this happen every year at the same time? When? ____________________________

How was this treated before (..z-pack et cetera..)? ________________________________

Emotions:

q Normal q Problem

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

q Anger q Anxiety

Emotions play role in balanced health and correct identification of trends can aid in restoring balance.

Do any of the following groups of emotions apply to you in your everyday life? (check all that apply:

____ I hide my feelings behind a façade of ____I often feel spacey and absent minded

cheerfulness _____I find myself unable to concentrate

____ I dislike arguments and often give in to _____I get drowsy and sleep more than most

avoid a conflict

____ I turn to food, work, alcohol, drugs when ____I am overly concerned with cleanliness

down ____I feel unclean or unattractive

____I tend to obsess over little things

____I feel anxious without knowing why

____I have a secret fear that something bad ____I feel overwhelmed by responsibilities

will happen ____I have temporarily lost self-confidence

____I wake up feeling anxious ____I don’t cope well under pressure

____I get annoyed by the habits of others ___I become discouraged with set-backs

____I focus on others’ mistakes ___I am disheartened when things get hard

____I am critical and intolerant ___I am often skeptical and pessimistic

____ I often neglect my own needs to please others ___I feel hopeless and can’t see a way out

____ I find it hard to say “no” ___I lack faith that life will improve

____I tend to be easily influenced ___I feel sullen and depressed

___ I constantly second-guess myself ___I am obsessed with my own troubles

____I seek advice, mistrusting my own intuition ___I dislike being alone and like to talk

____I often change my mind out of confusion ___I usually like talking about myself

____I’m afraid I might lose control of myself ___I am suspicious of others

____ I have sudden fits of rage ___I feel discontented and unhappy

____ I feel like I am going crazy ___I am full of jealousy, mistrust or hate

____I make the same mistakes over and over ___I’m often homesick for “the way it was”

____I don’t learn from my experience ___I think more about past than present

____I keep repeating the same patterns ___I often think about what might have been

____I need to be needed and want my loved ones ___I often feel too tired to face the day ahead

close ___I feel mentally exhausted

____ I feel unloved and unappreciated by ___I tend to put things off

my family

____ I easily feel slighted and hurt

____I find it hard to wait for things ____I lack self-confidence

____I am impatient and irritable ____I feel inferior and am discouraged

____I prefer to work alone ____I never expect anything but failure

____I am afraid of things such as spiders, illness ____I feel extreme heartache

____I am shy, overly sensitive and modest ____I have reached the limits of endurance

____I get nervous and embarrassed ____I am in complete despair, all hope gone

____I get depressed without reason ___I get high strung and very intense

____I feel my moods swinging back and forth ___I try to convince others of my opinions

____I get gloomy feeling that come and go ___I am sensitive to injustice, fanatical

____I tend to overwork even when exhausted ____I tend to take charge of projects

____I have strong sense of duty ____I consider myself a leader

____I neglect my own needs to finish tasks ____I am strong-willed and bossy

____I feel completely exhausted ____I am experiencing change in my life

____I am totally drained of energy no reserve ____I get drained by people or situations

____I have been through a long period of stress ____I want to be free to follow ambitions

____I feel unworthy and inferior ____I give the impression that I’m aloof

____I often feel guilty ____I prefer to be alone when overwhelmed

____I blame myself for things that go wrong ____I often don’t connect with people

____I am overly worried about loved ones ____I constantly have unwanted thoughts

____I am distressed by problems of others ____I relive unhappy events or arguments

____I worry that harm may come to loved ones ____I am unable to shut my mind off to sleep

____I sometimes feel terror and panic ___I can’t find my path in life

____I become helpless and frozen when afraid ___I am drifting in life and lack direction

____I suffer from nightmares ___I am ambitious but unfocused

____I set high standards for myself ___I am apathetic and resigned to whatever

____I am disciplined with health, work ___I have the attitude “it doesn’t matter”

____I am always striving for perfection ___I feel no joy in life

____I find it difficult to make decisions ___I feel resentful and bitter

____I often change my mind ___I have difficulty forgiving and forgetting

____I have intense mood swings ___I think life is unfair think “poor me”

____I feel devastated due to recent shock

____I am withdrawn due to traumatic events in my life

____I have never recovered from loss or fright

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: _____________________________________________________________________

_____________________________________________________________________________

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:

Regular exercise:

Type_______________ Frequency___________

Type________________ Frequency___________

Menstrual:

What was the date of your last period?__________________ How long do they last? ________

Are you on oral contraception (OCP)? __________ At what age did you first use OCP?______

Did you first use OCPs for menstrual pain or period regulation? _______

Are you prone to : PMS________ Bloating __________ Irritability________

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

Sensitivity and Allergies:

q No q Yes

q Cold q Hot q Dampness q Light q Noise or Radiation

q Airborne particles q Food q Drugs q Weather changes q Pet Dander

Do you eat eggs? ________ (yes or no)

Do you eat gluten or gluten products (wheat, oat, corn)?________

Do you eat dairy (yogurt, cheese, cow’s milk, ice cream, cream)? _________

Do you eat soy or soy products?____________

Do you cough up phlegm or get phlegm in response to eating certain foods?_______

Do you have post-nasal drip?__________

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 pre-menstrually? 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