Form Head To Heal Acupuncture Intake Patient Name: Date of Birth: / / Address: Phone: In case of emergency contact (name & #): Consent to treat with acupuncture (signature): Major Concerns: 1) 3) 2) 4) Details regarding Major Complaint: Where is the problem located? When did it start? Have you had this pain before? When? How did it start? Is it getting worse? coming and going getting better How often does it bother you? Is there a pattern- Time of day Time of year/ season What makes it better? Heat Cold Pressure Other What makes it worse? Heat Cold Pressure Other Describe the pain: Dull/Aches Shooting Other (pin prick, tight, squeezing, band sensation, expanding ) Does the pain radiate anywhere? Severity of pain out of 10 (10= worst pain)
Skin: Do you have any skin conditions? Yes No Do you have: Dry skin Itchy Moist/clammy Burning changing moles or lumps cysts boils frequent skin rashes Acne hair loss/thinning dry scalp puffy skin wrinkles easy to bruise hives scars (from what?) Other Head: Do you get headaches? Yes No how often? What area of the head? Temples behind eyes at top of head Side(s) back one sided worse side Do you have: memory loss? loss of balance dizziness Eyes: How is your vision? Any changes to your vision? Do you have? Blurred vision Redness Night blindness dry eyes decreased vision floaters: both eyes Lots few Ears: How is your hearing? any recent changes to your hearing Have you experienced deafness in either or both ears? Was the onset gradual or sudden Have you experienced ringing of the ears? if so, check the following: High pitched worse with pressure low pitched gradual onset better with pressure Have you had ear aches? ear discharges infections Nose:
Nose bleeds frequently sinus trouble frequent colds other Throat: Sore throat (describe) hoarse difficulty swallowing teeth or gum problems swollen tongue Respiration and Voice: Are you a loud talker soft talker Do you need to constantly clear your throat? Do you get frequent coughs? If so, which kind: feeble(weak) asthma Dry cough with phlegm production that is too sticky to cough up Dry cough with small amounts of: phlegm blood tinged Cough with lots of phlegm persistent cough other Consistency of phlegm colour Breathing: difficulty wheezing mucus rattles when breathing troubles breathing at night do you need 2+ pillows when sleeping? Shortness of breath? Yes no when? If so, is it: worse on exertion? worse with a cough/asthma? Associated with: heart palpitations emotional problems loose stools low back pain/arthritis Chest: pain pressure palpitations heart disease Other Blood Pressure: high low Digestion: how is your digestion? How many bowel movements do you have daily? Stool consistency: hard soft loose diarrhea undigested food blood mucus Do your stools: sink float Colour: honey brown grey black green red bloody streaked with red multiple colours other Check if appropriate: Loose stool: watery with mucus undigested food and cold symptoms undigested food, bloating and gas early morning diarrhea (around 5am) frequent with pain on defecation
Constipation: dry and malodorous dry with fatigue dry with cold symptoms Alternating loose stools then hard dry then loose pain on defecation and anal burning heavy, bearing down sensation in the anus mucous stool hemorrhoids malodorous stool bloating red and swollen gums indigestion/ heart burn Belching sour regurgitation Urine: Colour: light dark other Excess urination urination at night infrequent or unable to urinate blood in urine frequent bladder infections water retention where? other Does your water intake equal your output? any incontinence? Thirst: How much water do you drink/day? litres Excess thirst No thirst Do you: chug or sip Temperature preference of beverages Appetite: Excess appetite Poor appetite Appetite keeps changing Feel tired or weak if meal missed What are your food cravings? Musculoskeletal: Pain in: neck shoulder between shoulders arms hands fingers hip knee big toe upper back mid back low back sore bones loss of grip swollen knees/elbows leg cramps at night leg weakness weak ankles stiff all over tingling? where? muscle spasm cramps loss of feeling where? painful joints bursitis other Neurological : Nervous depressed easily angered easily irritated frequent crying worry/anxiety mood swings memory confusion poor concentration suicidal tremors
numbness /tingling coordination problems muscle weakness other Female: Age started menses age stopped menses vaginal discharge: yellow clear white yellow thick itching odor resembling Menstrual pain? low back pain irregular menses no menses clots with menses size colour: purple-red black-red bright red brown flow at beginning of menses number of pads or tampons used per day heavy light bleeding Water retention where? breast tenderness moodiness Low sex drive high hot flashes when? food cravings Pregnant Last monthly period Last PAP test / / Form of birth control # of pregnancies # of deliveries # of miscarriages # of abortions # of cesareans any operations: cervix uterus ovaries any cysts fibroids endometriosis Male: Low sex drive lack of sex drive impotence ejaculation causing pain penile discharge? colour pain on urination Burning premature ejaculation prostate trouble other Do you get a daily morning erection? Yes no is it difficult to achieve an erection? Yes no Reproductive: Libido- high average low Has it increased decreased Have you experienced fertility issues? if so, which partner and what has been tested? other Temperature and Circulation: General temperature: Hot cold area:
Neutral do you sleep with: feet out light covers no covers normal lots of covers do you need to wear many layers to keep warm do you like: warm drinks spicy foods are you cooler than others do you like cold, raw foods do you get a warm sensation around your chest, palms and soles of your feet all at the same time do you bleed easily do you have cold hands/feet Sweating: Rarely sweat excess sweating night sweat If you have night sweats do you wake in a full sweat, not aware that you were sweating, then it stops when awake or moving or do you sweat all night, you are aware of it, and it is due to the temperature of the room, and it does not change with moving Do you sweat spontaneously (not on exertion or with movement) do you find you are not sweating when others around you are? Sleep: Quality of sleep- poor good excellent Do you wake feeling refreshed? # of hours of sleep/night are you a morning person night person Is it hard to stay awake after eating do you nap Time how often do you need to nap? Do you have trouble falling asleep: with dizziness and /or heart palpitations with restlessness and dream disruption Following a big/late meal or with irritability Dreams: can t remember don t have them excess dreaming nightmares day dreaming Energy: Please rank your average daily energy out of 10 (10 = good) Mood: Please describe your mood The dominant emotion that you feel is: fear anger worry jealousy sadness grief depression joy other
Stress: None moderate severe cause How high is your stress out of 10 Nutrition: Do you: skip breakfast eat a snack hearty breakfast # meals per day biggest meal of the day is do you eat if you are worried or rushed # alcoholic drinks/week # cigarettes/day # of smoking years eat the same food mostly eat when not hungry snack at night hydrate without using water always add salt to meals eat until full eat many small meals throughout the day forget to eat I generally: make my own food eat out