TCM Intake Form
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Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Occupation
Contact Info
Mobile Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Additional Information
What are your main reasons for seeking treatment?
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When did this condition begin?
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What do you believe casued this condition(s)?
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What helps this condition(s)?
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What makes this condition(s) worse?
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Please list all current prescription medications, over-the-counter drugs, and supplements.
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Please select all current health care providers that you see for this condition(s)
Medical Doctor
Chiropractor
Acupuncturist
Herbalist
Physical Therapist
Embodiment Coach
Massage Therapist
Reiki Practitioner/Energy Worker
Do you follow any religious or spiritual practices?
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Health History
Medical History
Asthma
Autoimmune disorder
Allergies
Heart disease
Hypertension
History of heart attack
Stroke
Anemia
Headaches
Arthritis
Epilepsy
Kidney disease
Diabetes
Skin disorder
Infertility
Fibroids/cysts
Hepatitis
HIV
Tuberculosis
Cancer
Alcoholism/drug addiction
Depression
Mental illness
Weight problems
Surgeries
Physical trauma/accidents
Feel free to share any information about your answers from this section that you feel is relevant to your treatment.
Your Health and Well-Being
How would you rate your current level of health?
1
2
3
4
5
6
7
8
9
10
Very Poor
Excellent
How would you rate your current level of energy?
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2
3
4
5
6
7
8
9
10
Very Poor
Excellent
How would you rate your current emotional status?
1
2
3
4
5
6
7
8
9
10
Very Poor
Excellent
How do you feel upon getting up in the morning?
Refreshed
Takes awhile to get going
Tired
Do you feel sleepy during the day?
Yes
No
If so, what times of day do you feel sleepy?
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Select where you experience consistent sensations of heat, if any
Hands
Feet
Head
Abdomen
Low Back
Groin
Buttocks
Knees
Chest
Select where you experience consistent sensations of cold, if any
Hands
Feet
Head
Abdomen
Low Back
Groin
Buttocks
Knees
Chest
Pain
If you experience pain, please describe where the pain is located. Specify if the pain is dull, sharp, throbbing, or burning.
Does your pain improve with heat or cold?
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Does your pain improve or worsen when you apply pressure to that area(s)?
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Diet and Fluids
What type of drink do you prefer?
Hot
Cold
No preference
Are you thirsty a lot?
Yes
No
What type of food do you prefer?
Hot/warm, cooked meals
Cold/raw meals
No preference
Do you follow a special diet?
Vegetarian
Vegan
Diabetic
Other
If you answered "other," feel free to share what diet you follow.
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Number of cups of coffee you consume in a day
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Number of cans of soda you consume in a day (specify if you consume diet or regular soda)
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Number of alcoholic beverages you consume in a day
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Number of cigarettes you smoke in a day
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Sleep: Do you experience any of the following?
Difficulty falling asleep
Waking up frequently through night
Excessive sleeping
Dream disturbed sleep
Dreams that seem meaningful
Sleep talking
Nightmares
Sleep walking
How many hours a night do you sleep?
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If you wake up during the night, what times do you wake? Are you able to get back to sleep?
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LU/LI (Metal): Indicate if you have any of the following
Shortness of Breath
Asthma
Difficulty exhaling
Cough with sputum
Dry cough
Dry or itchy throat
Dry mouth
Nasal discharge
Poor sense of smell
Sinus problems
Rashes
Allergies
Catch colds easily
Sweating in day
Night sweats
Fatigue
Frequent grief, sorrow, or shame
Frequent dignity, inspiration, or integrity
SP/ST (Earth): Indicate if you have any of the following
Poor appetite
Excessive appetite
Loss of sense of taste
Craving sugar
Indigestion/belching
Abdominal distention/bloating
Excessive thirst
Thirst but no desire to drink
Weight gain/loss
Frequent gas
Bad breath
Nausea/Vomiting
Cold arms/legs
Hemorrhoids
Diarrhea
Gastric ulcers
Difficulty concentrating
Lethargic
Feeling of heaviness
Muscles often tired
Bruising or bleeding easily
Edema
Frequently over-thinking, obsessing, worrying, regretful, or remorseful
Frequently trusting, honest, balanced, open, impartial
How often do you have a bowel movement?
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Constipation
Diarrhea
Blood in stools
Pale stools
Dry stools or small pebble-like stools
Loose/soft
Loose stools alternating with small, dry stools
Mucous in stools
Undigested food in stools
HE/SI (Fire): Indicate if you have any of the following
Heart Palpitations
Chest pain
Blood pressure low
Blood pressure high
Chest pain
Dizziness
Insomnia
Difficulty falling asleep
Bitter taste in morning
Vivid dreams
Dream disturbed sleep
Waking frequently in night
Fainting
Long term memory problems
Frequently anxious, nervous, easily startled, restless
Frequently peaceful, calm, or orderly
KI/BL (Water): Indicate if you have any of the following
Difficulty inhaling
Poor short term memory
Kidney stones
Feel cold easily
Weak teeth or bones
Hearing problems
Tinnitus (ringing in ears)
Earaches/ infections
Hair loss
Hair graying
Low back pain
Weak or cold knees
Fertility issues
Frequently fearful, insecure, in shock, or lonely
Frequently experience clarity, wisdom, gentleness, or self-understanding
Urination: Select all that apply currently
Urgent
Clear
Painful
Yellow
Difficult
Cloudy
Frequent
Dark
Scant
Incontinent
Large amounts
Do you have a history of kidney stones? Urinary tract infections?
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Is your libido (sex drive)
Low
Normal
High
LIV/GB (Wood): Indicate if you have any of the following
Rib pain
Headache / migraine
Vomiting
Poor eyesight
Eyes sensitive to light
Other eye problems (Dry, itchy, sore, blurred)
Muscular cramps / spasms
High blood pressure
Neck stiffness / pain
Shoulder stiffness / pain
Dry skin / hair
Dizziness / vertigo
Brittle / ridged nails
Tinnitus, high pitched
Deafness
Depression
Procrastination / indecision
Allergies to fragrances or "scent sensitive"
Frequently feeling irritated, angry, frustrated, "wound up", or resentment
Frequently feeling kindness, compassion, or forgiveness
Female Health
Are you pregnant or trying to become pregnant?
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Start date of your last period
Length of your last period cycle
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What birth control method(s) do you currently use, if any?
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Number of pregnancies
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Number of live births
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Number of miscarriages
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Number of abortions
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Do you experience leukorrhea (vaginal discharge)? If so, is it white, yellow, or clear? Does it have an odor?
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Indicate what you commonly experience during your period
Early
Late
Regular
Alternating
Painful
Red
Dark red
Bright red
Pale or thin
Dark with clots
Brown
Heavy flow
Light flow
Normal flow
Spotting (during or outside of your cycle)
Cravings
Depresson
Crying
Fluid retention
Breast tenderness/swelling
Anxiety
Bloating
Weight gain
Headaches
Cramping
Dizziness
Irritability
Forgetfulness
Fatigue
Feel free to share any other gynecological or sexual issues that you feel are relevant to your treatment
Male Health: Indicate if you have any of the following
Impotence (difficulty attaining/maintaining erection)
Low libido
Premature ejaculation
Seminal emission
Sterility
Testicular swelling / pain
Involuntary night emissions (wet dreams)
Feel free to share any other sexual issues that you feel are relevant to your treatment
Miscellaneous
Is there anything else you'd like to share?
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