Traditional Chinese Medicine Intake Form
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Personal Info
First Name
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Contact Info
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City
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Australia
Canada
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Afghanistan
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Heard Island And Mcdonald Islands
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Iraq
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Virgin Islands, U.S.
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Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Additional Information
Height
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Weight
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Have you received acupuncture or Chinese herbs before?
Yes
No
Main reason(s) you are seeking treatment:
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When did this condition begin?
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Have you been given a diagnosis by a Doctor? If so, what?
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Health History
Conditions
Cancer, Type:
Diabetes
Hepatitis
High Blood Pressure
Heart Disease
Rheumatic Fever
Thyroid Disease
Seizures
Allergies / Asthma
AIDS / HIV+
Arthritis
Herpes
Anemia
Mental Illness
Other Illness:
Allergies
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Occupational Stresses (Chemical, Physical, Psychological):
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Do you exercise regularly?:
Yes
No
Habits/Frequency
Cigarettes/Day
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Alcohol/Week
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Caffeine/Day
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Recreational Drugs/Week
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Glasses Water/Day
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What relieves the pain (heat, cold, massage, rest, exercise, etc.)?
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What aggravates the pain (weather, heat, cold, etc.)?
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Rate your pain.
0
1
2
3
4
5
No Pain
Severe PAin
Currently Seeing the Following Professional:
Chiropractor
Naturopath
Physiotherapist
Massage Therapist
Other:
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Cardiovascular:
High Blood Pressure
High Cholesterol
Heart Palpitations
Low Blood Pressure
Fainting
Neck Stiffness
Chest Pain or Tightness
Cold Hands/Feet
Difficulty Breathing
Irregular Heartbeat
Swelling in hands/
Other:
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Respiratory:
Chronic Cough
Pneumonia
Production of Phlegm (what colour?)
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Coughing Blood
Hay Fever/Allergies
Asthma
Sinus Problems
Bronchitis
Tight Chest
Difficulty Breathing When
Lying Down
Other:
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Gastrointestinal:
Nausea
Gas
Vomiting
Pain or Cramps
Belching
Hiccups
Sensitive Abdomen
Bad Breath
Hemorrhoids
Rectal Pain
Itchy Anus
Black Stool
Bloody Stool
Diarrhea
Constipation
Alternating Loose/Constipation
Laxative use:
Laxative Type:
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Laxative Frequency:
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Bowel Movements: What is the Frequency, Colour, Odor, and Texture/Form?
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Muscle and Joints:
Neck Pain
Spinal Curvature
Weakness
Muscle Pain
Difficulty Walking
Body Heaviness
Body Aches/Stiffness
Joint Pains (Where):
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Back Pain (Where):
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Other:
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Neuropsychological/Emotions:
Seizures
Easily Stressed
Anxious
Relaxed/Calm
Sadness
Grief
Fearful
Anxiety
Depression
Angry/Frustrated
Irritability Often/Easily
Poor Memory
Bad Temper
Over Thinking
Manic
Impatient
Concussion
Areas of Numbness
Considered/Attempted Suicide
Treated for Emotional Problems
Other:
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Genito-Urinary:
Pain on Urination
Unable to Hold Urine
Urgency to Urinate
Frequent Urination
Blood in Urine
Excessive or Scanty Urination
Bedwetting
Kidney Stones
Venereal Disease
Pain/Itching Genitalia
Genital Lesions/Discharge
Impotency
Decreased Libido
Wake up to Urinate (frequency and what time)
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Other:
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Ears:
Ringing in Ears
Poor Hearing
Earaches
Other:
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Eyes:
Eyestrain
Colour Blindness
Spots/Floaters
Eye Pain
Cataracts
Glasses
Poor Vision
Blurry Vision
Red/Burning Itchy Eyes
Night Blindness
Other:
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Nose, Throat, Mouth, Head:
Teeth Problems
Gum Problems
Swollen Glands
Copious Saliva
Sores on Lips or Tongue
Dizziness
Nose Bleeds
Dry Mouth
Grinding Teeth
Facial Pain
Enlarged Lymph Glands
Migraines
Sinus Problems
Dry Throat
Bitter Taste in Mouth
Mucus
Dry Mouth/Thirsty
Recurrent Sore Throats (frequency per month)
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Other:
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Skin and Hair:
Itching/Dryness
Eczema/Psoriasis
Acne
Bruise Easily
Hives
Rashes
Changes in Hair/Skin Texture
Ulcerations
Hot Flashes
Night Sweats
Loss of Hair
Easily/Spontaneous Sweating
Dandruff
Nails Break Easily
Other:
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How Well Do You Sleep?:
Sound/Restful
Insomnia
Dream Disturbed
Heavy Sleep
Difficulty Falling Asleep
Vivid Dreams/Nightmares
Wake Up Easily/Early
Light Sleep
Hours of Sleep/Night:
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Are you stressed or relaxed?:
1
2
3
4
5
Relaxed
Stressed
What is your energy level?:
1
2
3
4
5
Low
High
Appetite?:
Normal/Healthy
Hungry, but no appetite
Ravishing Hunger
Poor Appetite
Need to eat several meals
Any taste in mouth?
Yes
No
Preferred Flavour:
Bitter
Sweet
Spicy
Salty
Sour
Preferred Drinks:
Warm
Cold
Other
For Women - Pregnancy and Gynecology:
Clots
Vaginal Sores
Vaginal Discharged
Breast Lumps
Menopause
Irregular Periods
Currently Pregnant
Currently Nursing
Age at First Menses:
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Flow (Describe):
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Last Menses:
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Menses Duration:
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Birth Control Type:
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Birth Control Duration:
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Last Pap Smear:
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Number of Pregnancies:
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Number of births:
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Miscarriages:
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Premature Births:
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