CHINESE MEDICINE PATIENT INTAKE FORM

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CHINESE MEDICINE PATIENT INTAKE FORM Please take a few minutes to complete this form to the best of your ability. The information provided in this form will help to provide me with a general overview of your health from a Traditional Chinese Medicine perspective, and assist me in preparing a treatment plan that will best meet your individual health needs and goals. CHILLS AND FEVER Do you ever have any of the following? chills fever both chills and fever If so, please describe (how often, how long, time of day or circumstances, etc) PERSPIRATION Do you perspire? Y N If so, do you perspire after slight exertion? Y N Any odours or colour to the perspiration? Do you perspire at night? Y N Do you perspire spontaneously? Y N HEAD AND BODY Do you experience headaches? Y N What time of day do the headaches begin? Where do the headaches occur (front, back, side of head, etc)? What is the character of the headache (sharp, dull, throbbing, etc)? Is there anything that makes the headaches better or worse (i.e., pressure, hot or cold applications, etc? Do you ever experience dizziness? Y N please describe: Do you ever experience pain anywhere in your body? Y N Type of pain (dull, sharp, throbbing, etc): Does the pain stay in one location or does it move around? Do you have any other symptoms associated with the pain (fatigue, nausea, etc)? Do you ever experience swelling in your joints? Y N Which joints? Is there any redness or heat in the joints that occurs with the swelling? Y N Do you ever experience numbness anywhere in your body? Y N

CHEST AND ABDOMEN Do have any chest pain? Y N Type of pain (sharp, dull, crushing, heavy, aching, etc): Does the pain radiate anywhere? Do you ever have palpitations? Y N Do you ever have anxiety? Y N Do you have asthma? Y N Do you have a cough? Y N Is there a particular time of day that it occurs? Is the cough strong (hacking) or weak? Is it wet or dry? Do you have any phlegm/sputum with the cough? Y N what is the colour and consistency (thick, watery, foamy, etc)? Do you have any difficulty breathing? Y N please describe: Do you ever experience abdominal distension, pain, or a feeling of fullness in the abdomen? Y N (upper, lower, middle) (bowel movements, eating, etc)? If there is pain, describe the nature (sharp, dull, cramping): APPETITE, THIRST AND TASTE How is your appetite? Any changes in your appetite? Any weight gain or loss? If so, please describe amount and over what period of time How is your thirst? How much water/fluid do you drink per day? Any preference for hot or cold drinks? Do you tend to sip or gulp your drinks? Any particular food cravings? Any unusual tastes in your mouth? (e.g., bitter, sweet, salty, etc)? Any bloating or gas? Any belching, acid reflux, or vomiting?

STOOL & URINE Do you get constipated or have diarrhea? Number of bowel movements per day: Is the colour of the urine clear, yellow, dark, or cloudy? Any pain or difficulty with either urination or defecation? What is the consistency of your stool (hard, formed, loose, watery, soft, dry, etc)? Any undigested food, mucous, or blood in the stool? SLEEP Do you sleep well? Y N Hours of sleep per night: Do you have any trouble falling or staying asleep? Y N Do you frequently dream or have nightmares? EARS & EYES How is your hearing? Have you noticed any changes to your hearing recently? Have you experienced deafness in either (specify) or both ears? was the hearing loss sudden or gradual? Do you ever experience ringing in either (specify) or both ears? Is the ringing low-pitched? high-pitched? Is the ringing constant? comes and goes? Did the ringing begin suddenly? come on gradually? Is there anything that makes the ringing better or worse (e.g., pressure)? How is your vision? Have you noticed any changes to your vision lately? Do you ever experience: Blurred vision? Red eyes? Night blindness? Dry eyes? Floaters? MENSES AND LEUKORRHEA (Females) Is your period the same each month? Y N Number of days in cycle: How many days is your period? Number of pads or tampons, on average, used during heaviest day of period: What colour is your flow (dark red, bright red, brown, etc)? Any clots in your period? Y N Any vaginal discharge? Y N If so, please describe the colour, consistency, and odour Is there anything else that you would like to mention that has not been covered or feel it is important for me to be aware of?

Review of Systems Please place a checkmark ( ) next to any of the following symptoms that you currently experience and a (P) next to any that you have had in the past SKIN & HAIR Rashes Itching Eczema Psoriasis Boils/Cysts Acne Hives Warts Colour changes New/Changed moles Lumps Dandruff Hair loss Change in hair texture Nail changes EYES Impaired vision Glasses/contacts Far-sighted Near-sighted Double vision Colour blindness Night blindness Sensitivity to sun Pain Redness Itching Discharge Blurring Excessive tearing Spots/Floaters Blind spot Glaucoma Cataracts EARS Ringing Discharge Pain/Aches Deafness Infections Wax build-up Ear tubes NOSE & SINUSES Allergies Loss of smell Post nasal drip Nosebleeds Sinus infections Sinus pain Nasal congestion Sleep apnea Snoring Nasal Polyps MOUTH & THROAT Dental cavities Mercury fillings Gum problems Grinding/Clenching Ulcers/sores Loss of Taste Pain/Soreness Frequent Sore throat Hoarseness Tonsillitis Phlegm/Mucous Cold sores Enlarged glands Jaw pain/clicking Facial pain/tics HEAD & NECK Headache Injury Lumps Swollen glands Swollen lymph nodes Goitre Pain/stiffness RESPIRATORY Cough Sputum Coughing blood Wheezing Asthma Bronchitis Pneumonia Emphysema Tuberculosis Difficulty breathing pain with breathing shortness of breath (SOB) SOB lying down SOB at night CARDIOVASCULAR High blood pressure Low blood pressure Irregular heart beat Fast heart beat Slow heart beat Palpitations Murmurs Angina Chest pain Swelling of limbs Cold hands or feet Thrombophlebitis Blood clots Varicose veins Elevated cholesterol Past ECG test Heart tests BLOOD & LYMPHATIC Anemia Easy bruising/bleeding Slow clotting Fatigue/weakness Pallor (paleness) Swollen lymph nodes Past transfusions

GASTROINTESTINAL Heartburn/acid reflux Indigestion Poor/change in appetite Poor/change in thirst Difficulty swallowing Abdominal pain/cramps Bloating Gas or belching Bad breath Diarrhea Constipation Incomplete bowel movements Nausea Vomiting Vomiting blood Spitting blood Chronic laxative use Rectal pain Rectal bleeding Rectal incontinence Hemorrhoids Blood in stool Black, tarry stools Undigested food in stool Mucous in stool Hernia Ulcer Candida Intestinal worms Liver disease Gall bladder stones/disease Jaundice Anal itching Anal fistula Anal fissures Food allergies GENITOURINARY Frequent urination Pain/burning on urination Urgency to urinate Urinary incontinence Hesitancy with urination Waking at night to urinate Recurrent urinary tract Infections Kidney infection Kidney stones Blood in urine Low back pain Flank (side) pain ENDOCRINE Excessive urination Excessive sweating Heat intolerance Cold intolerance Thyroid disease Excessive thirst Excessive hunger Diabetes Hypoglycemia Hormone Therapy Rapid weight gain Rapid weight loss Insomnia MUSCULOSKELETAL Back pain Muscle spasms/cramps Muscle weakness Arthritis Tendonitis Jaw pain/stiffness Joint pain/stiffness Joint swelling Bursitis Fractures Osteoporosis Sciatica NEUROLOGICAL Dizziness Seizures Fainting Paralysis Stroke Poor memory Loss of balance Concussion Numbness/Tingling Tremors Speech difficulty Poor coordination Confusion Dementia Learning difficulties Involuntary movements FEMALE REPRODUCTIVE Heavy menses Light menses Irregular periods Painful periods Bleeding between periods Menstrual blood clots Vaginal discharge Vaginal itching Vaginal sores Yeast infections Painful intercourse Low libido sexual difficulty Fibroids Ovarian cysts/pcos Endometriosis Hysterectomy Menopause Difficulty conceiving Sexually transmitted disease Sexually active Birth control/protection Form: MALE REPRODUCTIVE Testicular masses Testicular pain Hernia Prostate problems Discharge or sores Low libido Erectile dysfunction Premature ejaculation Low sperm count sexual difficulty Sexually transmitted disease Sexually active Use regular protection Form: EMOTIONAL/PSYCHOSOCIAL Depression Anxiety Mood swings or Irritability Phobias Hyperactivity Aggression Alcohol/Drug Abuse

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