Privacy: Please be assured that everything submitted on this intake form and shared during any consultation is completely confidential between the client and the practitioner.

* indicates a required field.

Your name*:

Your Address*:

Your Home Phone:

Your Work Phone:

Best time(s) to call:

Your email*:

Preferred form of contact*:

Occupation*:

Gender*:

Age*:

Height*:

Weight*:

Birth Date*:

Who do you share your home with?

Number of children:

Their Age(s):

Please list all physicians and other healthcare providers or consultants (such as Acupuncturist, massage therapist, etc) you see on a regular basis:

Name, Location, Type of Service:

Would you like me to contact them regarding your health plan with me? YesNo

Family Medical History:
Please describe any relevant or major health-related issues:

Father:

Mother:

Maternal Grandmother:

Maternal Grandfather:

Paternal Grandmother:

Paternal Grandfather:

Other family members with pertinent issues, or recurring family health trends:

Present Health Status:

Do you currently smoke tobacco? YesNo

If so, how many cigarettes/day?

If not, have you ever been a smoker in the past? YesNo

For how many years did you smoke?

When did you quit?

Do you currently drink alcohol? YesNo

If so, list type, quantity, and frequency:

Did you consume alcohol in the past? YesNo

When did you quit alcohol?

If so list type, quantity and frequency:

List form and frequency of any regular exercise:

How is your digestive system overall, do you experience indigestion, gas, constipation, diarrhea, bloating or other:

How often do you have a bowel movement?

How often do you urinate and what is the character of your urine, i.e., light, dark, strong odor?

Check each item where symptoms apply and elaborate in space provided below if necessary.

Cardiovascular Skin

High Blood Pressure: N/Asometimes experienceoccurs oftenmajor concern

Low Blood Pressure: N/Asometimes experienceoccurs oftenmajor concern

Boils: N/Asometimes experienceoccurs oftenmajor concern

Bruises: N/Asometimes experienceoccurs oftenmajor concern

Pain in Heart: N/Asometimes experienceoccurs oftenmajor concern

Dryness: N/Asometimes experienceoccurs oftenmajor concern

Poor Circulation/Cold Extremities: N/Asometimes experienceoccurs oftenmajor concern

Itching: N/Asometimes experienceoccurs oftenmajor concern

Swelling in Ankles/Joints: N/Asometimes experienceoccurs oftenmajor concern

Varicose Veins: N/Asometimes experienceoccurs oftenmajor concern

Previous Heart Stroke/Murmur: N/Asometimes experienceoccurs oftenmajor concern

Skin Eruptions: N/Asometimes experienceoccurs oftenmajor concern

High Cholesterol: N/Asometimes experienceoccurs oftenmajor concern

Muscles/Joints Respiratory

Backache/Upper or Lower: N/Asometimes experienceoccurs oftenmajor concern

Chest Pain: N/Asometimes experienceoccurs oftenmajor concern

Broken Bones: N/Asometimes experienceoccurs oftenmajor concern

Difficulty Breathing: N/Asometimes experienceoccurs oftenmajor concern

Mobility Restriction: N/Asometimes experienceoccurs oftenmajor concern

Cough: N/Asometimes experienceoccurs oftenmajor concern

Arthritis/Bursitis: N/Asometimes experienceoccurs oftenmajor concern

Tuberculosis: N/Asometimes experienceoccurs oftenmajor concern

Congestion: N/Asometimes experienceoccurs oftenmajor concern

Eyes, Ears, Nose, Throat and Gastro-Intestinal

Asthma: N/Asometimes experienceoccurs oftenmajor concern

Belching: N/Asometimes experienceoccurs oftenmajor concern

Ear Aches: N/Asometimes experienceoccurs oftenmajor concern

Colitis: N/Asometimes experienceoccurs oftenmajor concern

Eye Pains, Dry/Wet Eyes: N/Asometimes experienceoccurs oftenmajor concern

Constipation: N/Asometimes experienceoccurs oftenmajor concern

Failing Vision: N/Asometimes experienceoccurs oftenmajor concern

Abdominal Pain: N/Asometimes experienceoccurs oftenmajor concern

Hay Fever: N/Asometimes experienceoccurs oftenmajor concern

Liver Problems: N/Asometimes experienceoccurs oftenmajor concern

Sinus Infection: N/Asometimes experienceoccurs oftenmajor concern

Gall Stones: N/Asometimes experienceoccurs oftenmajor concern

Sinus Congestion: N/Asometimes experienceoccurs oftenmajor concern

Ulcers: N/Asometimes experienceoccurs oftenmajor concern

Sore Throat: N/Asometimes experienceoccurs oftenmajor concern

Indigestion: N/Asometimes experienceoccurs oftenmajor concern

Tonsils: N/Asometimes experienceoccurs oftenmajor concern

Hearing Loss/Ringing Ears: N/Asometimes experienceoccurs oftenmajor concern

Sleeping Patterns

Insomnia: N/Asometimes experienceoccurs oftenmajor concern

Waking in the night: N/Asometimes experienceoccurs oftenmajor concern

Night sweats: N/Asometimes experienceoccurs oftenmajor concern

Restless sleep: N/Asometimes experienceoccurs oftenmajor concern

Wake up tired: N/Asometimes experienceoccurs oftenmajor concern

Difficulty falling back to sleep: N/Asometimes experienceoccurs oftenmajor concern

Urinary/Kidney

Excessive Urination: N/Asometimes experienceoccurs oftenmajor concern

Water Retention: N/Asometimes experienceoccurs oftenmajor concern

Burning Urine: N/Asometimes experienceoccurs oftenmajor concern

Kidney Stones: N/Asometimes experienceoccurs oftenmajor concern

Miscellaneous

Lower Back Pain: N/Asometimes experienceoccurs oftenmajor concern

Dark Circles Under Eyes: N/Asometimes experienceoccurs oftenmajor concern

Itchy Ears/Eyes: N/Asometimes experienceoccurs oftenmajor concern

Usually Feel Hot/Warm: N/Asometimes experienceoccurs oftenmajor concern

Usually Feel Cold/Cool: N/Asometimes experienceoccurs oftenmajor concern

Emotional Insecurity: N/Asometimes experienceoccurs oftenmajor concern

Do you have headaches? N/AYesNo

How often?

What are they like?

Do you know what causes them?

Common Physical Activities

What type(s) of Physical Activities do you do? Desk SittingStandingSitting in a carJogging/RunningCalisthenicsAerobicsSwimmingWeight LiftingWalkingYogaTai ChiHikingBike RidingHorseback RidingTennisBending/Lifting

How long do you sit at a desk?

How long do you stand?

How long do you sit in a car?

Any other phisical activities?

Do any of the conditions/physical activities above aggravate a current health condition? YesNo

If so, please explain:

Have you had any operations? YesNo

If so, please indicate what kind of operation(s) and the year each operation was performed :

Any major injuries/accidents? YesNo

If so, please indicate what kind of injury(ies) and the year each injury was occured:

Any major illness or hospitalizations? YesNo

If so, please indicate what kind of illness or hospitalization and the year each illness or hospitalization occured:

Dietary Information
Please check each item listed below if it is included in your daily - or usual - diet.
Mark if Daily, Weekly, Monthly or Never

Red Meat: DailyWeeklyMonthlyNever

Butter: DailyWeeklyMonthlyNever

Candy Bars/Chocolate: DailyWeeklyMonthlyNever

Fish: DailyWeeklyMonthlyNever

Milk: DailyWeeklyMonthlyNever

Coffee: DailyWeeklyMonthlyNever

Poultry: DailyWeeklyMonthlyNever

Cheese: DailyWeeklyMonthlyNever

Black Tea: DailyWeeklyMonthlyNever

Fruit: DailyWeeklyMonthlyNever

Yogurt: DailyWeeklyMonthlyNever

Herbal Tea: DailyWeeklyMonthlyNever

Vegetables: DailyWeeklyMonthlyNever

Sugar: DailyWeeklyMonthlyNever

Alcohol: DailyWeeklyMonthlyNever

Raw Foods: DailyWeeklyMonthlyNever

Honey: DailyWeeklyMonthlyNever

Vitamins: DailyWeeklyMonthlyNever

Grains: DailyWeeklyMonthlyNever

Baked Goods: DailyWeeklyMonthlyNever

Protein Supplements: DailyWeeklyMonthlyNever

Nuts: DailyWeeklyMonthlyNever

Deserts: DailyWeeklyMonthlyNever

Food Supplements: DailyWeeklyMonthlyNever

Seeds: DailyWeeklyMonthlyNever

Chips: DailyWeeklyMonthlyNever

Processed Foods/Snacks: DailyWeeklyMonthlyNever

Fermented Foods: DailyWeeklyMonthlyNever

Crackers: DailyWeeklyMonthlyNever

Describe below your typical meals. Please be as specific as possible. For example, Instead of "oil" list type of oil, such as olive, corn, etc. Instead of "bread" list whether white or whole grain, etc. Instead of "vegetables" list type of vegetable, how prepared, canned, frozen, or fresh, etc. Please include beverages, type and quantity (two cups of coffee, one glass of orange juice, etc.)

What’s a good day of eating like?

Breakfast:

Morning Snacks:

Lunch:

Afternoon Snacks:

Dinner:

Evening Snacks:

Daily water consumption (number of glasses/quantity per day):

What’s a bad day of eating like (meals on the run, etc)?

Breakfast:

Morning Snacks:

Lunch:

Afternoon Snacks:

Dinner:

Evening Snacks:

Daily water consumption (number of glasses/quantity per day):

How many times a week do you have a good day of eating?

How many times a week do you have a bad day of eating?

Please list any known food allergies/sensitivities:

Food Describe Reaction(s):

If everything was good for you, what would you want to eat (What do you crave)?

Have you ever had herb tea? YesNo

Current State of Emotions and Feelings
Please take a moment to answer the following questions:

Are you able to express your feelings and emotions?

Is there an excess of stress in your life?

What is causing the stress?

Are you satisfied with your job?

If in a relationship, are you satisfied with it?

If there is one thing in your life you would like to change right now, what is it?

Can you change it?

Are you a "nervous type" person?

What are the things that make you most nervous?

Have you a "super woman/superman" complex?

Do you sleep well? YesNo

How long do you sleep each night?

Do you nap? YesNo

How long do you nap?

How often do you nap?

Do you dream? YesNo

Do you remember your dreams?

Are you satisfied with your general energy level?

Do you often feel exhausted and fatigued?

Is it easy to wake up in the morning? YesNo

Which of these feelings dominate in your life? joyhappinessangersadnessfearsympathyworrydepression

If you were to choose two Emotions which seem predominant in your life, they would be...

Emotion 1:

Emotion 2:

Please indicate approximate dates and describe the nature of any traumatic experiences you have had in the past 7 years (divorce, loss of lover, loss of job, change of residents, injury, death, etc.):

Name one thing in life that you do that is really good for you:

Name one thing you know you should be doing but don’t:

What are your passions and interests?

What do you do for fun?

Supplements and Medications

List all herbs, vitamins, and dietary supplements you currently take, including dosages, citing the brand name whenever possible (please bring all your supplement bottles with you for your appointment):

List all medications you are currently taking and what they are taken for (including aspirin, antacids, etc.). Please include the dosage and frequency and indicate whether they are over the counter (OTC) or prescription (P):

Do you use any other drugs?

MarijuanaMushroomsEcstasyCocaineLSDHeroin

Other?

Have you used any drugs in the past?

MarijuanaMushroomsEcstasyCocaineLSDHeroin

Other?

List all medications, herbs, etc., to which you have a known allergy:

What are the areas of current complaint that you would like to address with an herbal program?*