Red Crow Sings East Asian Medicine
NEW CLIENT INTAKE FORM
Name Date
Address
City State Zip
Home Phone Work Phone
Cell Phone Email
Date of Birth Age Sex
Relationship Status
Occupation Employer
Emergency Contact & Relationship Phone
Referred? If Yes, by whom?
Have you ever received Acupuncture before? If yes, when?
What brought you to our office today? Briefly describe your main complaint(s):
#1
#2
#3
Briefly describe any other significant health conditions that are currently a cause for concern:
List any major accidents, surgeries or hospitalizations, including date or age at time of occurrence
List any current medications you are taking, and include reason:
List any supplements you are taking, and include reason:
List any current allergies:
When, where, and why, were you last been seen by a medical doctor?
Physician Date
Reason for Visit Diagnosis
MEDICAL HISTORY
Please check next to any of the following conditions, you, or a family member currently has, or has had, in the past:
Condition / Self / Current or Past (C or P) / Grandparent / Parent / SiblingDiabetes
Cancer
Heart Disease
High Blood Pressure
Low Blood Pressure
Allergies
Tuberculosis
Obesity
Bleeding Disorder
Kidney Disease
Alcoholism
Depression / Anxiety
Mental Illness
Stroke
Thyroid Disorder
Hepatitis
HIV
Asthma
Pneumonia
Emphysema
Epilepsy
Multiple Sclerosis
Migraines
Lifestyle:
Diet: □ Vegetarian □ Vegan □ Meat & Potatoes □ Fruits & Vegetables □ Fish Water intake per day
Caffeine intake: □ Coffee □ Tea □ Soda □ Energy Drinks # of cups per week
Alcohol intake: □ Beer □ Wine □ Hard Liquor □ None # per week
Smoke cigarettes: □ Yes □ No # of cigarettes per day
Recreational drugs: □ Yes □ No Type Frequency
Please place a check next to the following that pertain to you:
Body Temperature:
□ Cold hands □ Cold feet □ Sweaty hands
□ Sweaty feet □ Warm body temperature □ Cold body temperature
□ Afternoon hot flushes □ Night sweats □ Heat in the hands, feet, and chest
□ Hot flashes □ Thirsty □ Sweats' easily
□ Lack of sweating □ Face flushing
Overall Energy: circle one: Low Medium High
□ Shortness of breath □ General weakness □ Difficult to keep eyes open in day
□ Feel worse after exercise □ Feel better after exercise
□ Mental heaviness □ Mental sluggishness □ General heavy sensation in body
□ Mental fogginess □ Energy worse in morning □ Energy worse at end of day
Heart System:
□ Heart Palpitations □ Anxiety □ Sores on the tongue
□ Restlessness □ Mental confusion □ Chest pain traveling to shoulder
□ Frequent dreams □ Generally wakes unrefreshed □ Dizziness
□ Poor memory □ Difficulty concentrating □ Poor sleep or insomnia
Lung System:
□ Nasal discharge □ Cough □ Nosebleeds
□ Sinus congestion □ Dry mouth □ Dry throat
□ Dry nose □ Dry skin □ Allergies
□ Chills / fever □ Sneezing □ Frontal headache
□ Catch colds easily □ Shortness of breath □ Overall body aches
□ Stiff neck □ Sore throat □ Difficulty breathing
□ Sadness □ Melancholy
Spleen System:
□ Poor appetite □ Abrupt weight gain □ Abrupt weight loss
□ Abdominal bloating □ Abdominal gas □ Gurgling noise in stomach
□ Fatigue after eating □ Prolapsed organs □ Bruise easily
□ Hemorrhoids □ Loose stools □ Over-thinking
□ Over-worry □ Food allergies □ Anemia
Stomach System:
□ Bad breath □ Large appetite □ Burning sensation after eating
□ Heartburn □ Mouth sores □ Bleeding, swollen or painful gums
□ Ulcer □ Belching □ Hiccups
□ Stomach pain □ Nausea □ Vomiting
Liver / Gallbladder Systems:
□ Chest pain □ Tightness of chest □ Alternating diarrhea / constipation
□ Bitter taste in mouth □ Anger easily □ Alternating chills / fever
□ Frustration □ Irritability □ High stress
□ Skin rash □ Headache at top of head □ Sensation of lump in throat
□ Tingling sensation □ Numbness □ Muscle spasms, twitching, cramps
□ Seizures / convulsions □ Neck tension □ Neck and/or shoulder tension
□ Drink alcohol □ Drug use □ High pitch ringing in ears
□ Gallstones □ STDs □ See floaters in visual field
□ Itchy eyes □ Red and/or Bloodshot eyes □ Dry eyes
□ Heat sensation in eyes □ Watery eyes □ Gritty eyes
□ Blurry vision □ Poor night vision □ Wear glasses or contacts
Kidney / Urinary Bladder Systems:
□ Frequent tooth cavities □ Bones break easily □ Sore or weak knees
□ Cold sensation of knees □ Sore or weak low back □ Cold sensation of low back
□ Poor memory □ Excessive hair loss □ Low pitch ringing in ears
□ Kidney stones □ Bladder infections □ Wake at night to urinate
□ Lack of bladder control □ Fear □ Easily startled
Urination:
□ Dark yellow urine □ Reddish color urine □ Cloudy urine
□ Scanty urine □ Profuse urine □ Frequent urination
□ Strong odor to urine □ Burning with urination □ Painful urination
□ Hesitant urination □ Clear urine
Bowel Movements:
□ Loose □ Constipated □ Incomplete bowel movements
□ Diarrhea □ Blood in stool □ Mucus in stool
□ Undigested food in stool □ Early morning urgency □ Dry stools
Libido:
□ Normal □ High □ Low
Female Sexual History
Are you currently pregnant? □ Yes □ No If yes, how many weeks?
# of pregnancies # of living children
# of abortions # of miscarriages
Have you been through menopause? □Yes □ No At what age?
History of cesarean section? □ Yes □ No
Menstrual cycle regular? □ Yes □ No Number of days between periods
Average # of days of menstrual flow:
Color of menstrual flow: □ Fresh red □ Bright red □ Dark red □ Purple □ Brown □ Pink □ Rust red □ Other:
Amount of menstrual flow: □ Average □ Heavy □ Light
Consistency of menstrual flow: □ Thick □ Thin □ Mixed with mucus □ Clots □ Watery □ Normal
Pain during menstrual flow: □ None □ Mild □ Moderate □ Severe
Do you experience: □ Excessive vaginal discharge between periods
□ Bleeding between periods
Do you experience any of the following PMS symptoms:
□ Nausea □ Food cravings □ Depression
□ Vomiting □ Headaches □ Irritability
□ Water retention / bloating □ Migraines □ Anxiety
□ Breast swelling □ Breast tenderness □ Other emotions:
□ Cramps □ Dull pain □ Sharp pain
□ Other:
Have you ever been diagnosed with any of the following:
□ Uterine fibroids □ PCOS □ Ovarian cysts
□ Endometriosis □ Fallopian tube blockage □ Endometritis
□ Ectopic pregnancy □ Cervical dysplasia □ Infertility
□ Other gynecological conditions
Current or history of STDs? □ Yes □ No If yes, explain:
Male Sexual History
Do you have any of the following:
□ Swollen testes □ Testicular pain □ Impotence
□ Premature ejaculation □ Prostatitis □ Prostate enlargement
□ Infertility □ Seminal emission □ Pain with urination
□ Feeling of cold or numbness of external genitalia
□ Other
Current or history of STDs? □ Yes □ No If yes, explain:
6715 Greenwood Ave N Seattle, WA 98103 (206)-251-7109