Acupuncture Intake forms

•This is a copy and paste form. Thank you for taking the time to fill out all of your information. My goal is to see the big picture and how each area affects the other.

The Acupuncture Healing Center
New Patient Confidential Medical Intake Form

Name_____________________________________Home/Cell_____________________ Date_________ Email_______________________________________ Address__________________________________ Date of Birth _____________________
Is it okay to follow up with your treatment? Y N
How did you find the Acupuncture Healing Center?___________________________________________
Emergency Contact: Name/Number______________________________________________________
Have you had acupuncture before? Y N Chinese Herbal Medicine? Y N Reason for visit today:____________________________________________________________________________________________________________________________________________
How long have you had this condition?____________________________What seemed to be the initial cause?__________________________________________________________________________
Is this constant? Y N Comes and Goes? Y N Is it getting worse? Y N
What makes it better?______________________________worse?______________________________
Have you seen another doctor? Y N Have you had other treatment?_____________________________
What medications/supplements are you taking?________________________________________________________________________________________________________________________________________________________________

Past Medical History/Family History
Check what you have had Circle conditions you have. Mark F on family conditions
Addictions AIDS/HIV Alcoholism Allergies/medications Anemia Appendicitis Asthma Atherosclerosis/clogged arteries Auto-immune Birth Trauma Bladder Issues Bleeding Disorders Breathlessness Bowel Changes Breast Pains/Lumps Bruising Cancer Carpal Tunnel Chest Pains Chicken Pox Chronic Fatigue Constipation Crohns Circulatory/Vascular Problems Cold Hands/Feet Cold Sores COPD Continuous Coughing Depression Diabetes Diarrhea Difficulty Swallowing Disability Diverticulosis Eating Disorders Emphysema Emotional Changes Fainting Epstien-Barr Epilepsy Eye problems/watery/dryness/itchy Floaters Fertility Issues Fibroids Fibromyalgia Gallstones Genital Disorders Goiter Gout Hairloss Heart Disease Hepatitis A/B/C Headache Hernia Herpes High Cholesterol Hip Pain Incontinence Impotence Irritable Bowel Jaundice Joint Replacement Kidney issues Knee Pain Leukemia Weakness/Cramping/Stiffness/Spasms Multiple Sclerosis Mumps Mouth Pain Mono Nasal Congestion Neck Pain Numbness Odor Change Organ Transplant Polio Polycystic Disease Premature Ejaculation Psoriasis Rash Raynard’s Rheumatic/Scarlet/Typhoid-Fever Scoliosis Seizures Serious Illness STD Shingles Shoulder Pain   Skin Disorders Sinus Infections Sleep Disorders/Apnea Snake Bite Sores not Healing Sprained Ankle Spontaneous Sweating Stress Stroke Sudden Weight or Loss Surgeries_________________________
__________________________________________________ Thyroid Disorders Tuberculosis Trauma Ulcers Varicose Veins Vertigo Whooping Cough Yeast infections/Athletes Foot Fungus.  Do you feel more HOT or COLD? Any other data?_______________________________________________________

Your Appetite: Low__ Normal__ High__ Unusual__ Iced Drinks Y N Sometimes_ Always_ How much is your daily fluid intake? _____________ When is your biggest meal? ______________ Do you become sleepy after eating? Y N Do you crave sweets after eating? Y N Do you crave? Salty_ Sweet_ Bitter_ Do you eat? Veggies_ Meat_ Carbs_ Starches_ Do you diet? Y N Do you eat when worried__ on the go__ constantly__ only when hungry__? Do you drink alcohol beverages? Y N How often?_____

Bitter Taste Acid Regurgitation Belching Burning Sensation Bloating Constipation Diarrhea Esophageal Damage Food Allergies Gallstones Gas Gurgling Heartburn Hemorrhoids Hiccups Ingestion Nausea Rectal Itching/Pain Stomach Cramps/Pain Vomit Blood Ulcers Do you have daily bowel movements? Y N How Often_________? Your stool’s consistency is? Firm Hard Soft Pebbly Normal Watery Floating Undigested Food No-Consistency Bad Odor Bloody/Black/Mucous Alternates

Blood Clots Chest Pain Cold Hands/Feet Difficulty breathing when laying down Shortness of Breath Fainting High/Low Blood Pressure Palpitations Heart Attack Irregular Beat Murmur Phlebitis Poor Circulation Varicose Veins

Exercise and Energy
On a scale of 1-10. What is your energy now?____ What is it typically?_____ What time of the day is your Highest energy_____ and your Lowest_____? Do you fatigue easily? Y NDo you exercise, how often and what is it? ____________________________________________________________________

Emotions and Sleep
Do you have? Anxiety Anger Over Analyze Bad Temper Blame Compulsive Depression Difficulty making Decisions/Choices/Concentrating Fearful Frequent Crying Grief Guilt Irritability Judgmental Laugh Inappropriately Mental Health Issues Mood Swings Nervousness Numbness Obsess Panic Restless Sadness Stressed Suicidal Survivor of Abuse Worry What is your typical level of stress 1-10? _____ How do you handle or hold stress?___________________________________ Where does your body hold stress?___________________________________ How do you relax_____________________________________? Do you have difficulty? Falling Asleep Staying Asleep Disturbed Dreams Nightmares Sleepwalking Waking up and not being able to fall asleep and at what time? ________________What side do you sleep on? Right____ Left____ Stomach____ Back___ About how many hours do you sleep?___________

Eyes Ears Nose Throat and Head
Do you smoke? Y N Have you smoked? Y N Allergies Asthma Cataracts Dry Eyes Eye Strain Glaucoma Itchy/Painful/Red Eyes Poor/Blurry Vision Night Blindness See Floaters/Spots/Light Streaks Wear Glasses /Contacts Macular Denegation Chronic Runny Nose Nose Bleeds Frequent Colds Frequent Sore Throats Hoarseness Lump in Throat Ear Aches Ear Discharge Deafness/Poor Hearing Ringing in Ears Pain on Inhalation/Exhalation Shortness of Breath on Exertion/Rest Chronic Cough Teeth Problems TMJ Swollen Glands Enlarged Thyroid Headaches/Migraines Dizziness/Vertigo Other Head Neck Soft Tissue Issues?___________________________________________________________________
Genital Pain Impotence Incomplete Urination Interrupted Urination Pain on Ejaculation Premature Ejaculation Prostatitis BPH Spontaneous/Continuous/Unusual/ No Erection

Muscle Joint & Bone
Do you have pain or tightness? Y N Where? ________________________________________________
On a scale of 1-10, what level of pain are you experiencing with this condition?______ Is the pain? Sharp Shooting Stabbing Dull Achy Numb Superficial Deep Burning Constant Cold Hot Pins and Needles Tingling Radiating Throbbing Better with Cold/Hot Worse with Cold/Hot Better/Worse with Pressure Do you have? Arthritis/Joint Pain Swollen Joints Bone Pain Fractured Bones where and when? ____________________________________________________________________

Muscle Cramping/Spasms/Weakness/Numbness/Pain Repetitive Strain Neck Pain Shoulder Pain Elbow Pain Does it get better? Y N How and or When? _______________________________________

Skin & Hair
Do you have Dry/Moist/Clammy Skin Itchy/Red/Pink Skin Acne Eczema Hives Hair Loss Dandruff Dry Brittle Hair Dry/Brittle/Thin Nails Psoriasis Boils Bruise Easily Oily/Thin/Thick Skin Scars Excessive/Night Sweating

Urine color is: Pale Light Yellow Yellow Dark Yellow Orangey/Brownish Routine Amount is: Copious Frequent Scanty/Little Normal Do you have? Abnormal Discharge Blood in Urine Burning Bedwetting Difficulty Urinating Frequent Urination Incontinence Leaking when Cough or Sneeze Strong Smelling Urine Water Retention Frequent Infections Swelling of legs Get up at night to urinate? Y N How many times? ___ Approximate time? _________

This information gives details of your inner Jing/Essence energy. Do you have? Cramping Irregular Cycles Heavy/Light No Flow Clots Spotting Between Cycles Vaginal Itching Sores Mood Changes Menopause Hot Flashes Breast Swelling/Pain/Lumps Discomfort/Pain/Before/During Cycle When was your last cycle?_______________ Days of Flow?_____ Days between cycles? _____ Color of Menstruation is Pale/Pink/Normal/Dark Red/Purple/Black What age did you start menstruation?______ Do you use Birth Control? Y N What Type?____________________ Number of Pregnancies?____ Deliveries?_____Miscarriage?_____
Thank you kindly for filling out the details!
~ Disclaimer: results or specific results are not guaranteed ~

A fee of $10.00 extra for the first community acupuncture visit.


Consent for Community Acupuncture

I _______________________________________________ on DATE________

consent for Leslie Kim Gray L.Ac to preform acupuncture and Chinese Medical procedures on me in a semi- public community acupuncture setting.

A white board for written communication will be utilized for privacy in communication. I am aware that we may need to speak specifically about the reason I am having acupuncture and others may hear some of my conversation of my health. _____-initial

I realize all of my health records will be held confidential and protected under HIPPA law and will not be released with-out my written consent, and that some spoken communication may occur in community acupuncture treatment. _____-initial

I understand that acupuncture can cause bleeding, bruising, infection even with sterile needles, achiness, fatigue feeling, dizziness or light headed, emotional release, itchiness, a numb sensation, increase in pain after a treatment being the Qi and blood stagnation are moving through a stuck place in the body in a negative way. In a positive way acupuncture has pain relief, improved sleep and a more balanced mood. _____-initial

Moxibustion can cause a blistering or a burn, this is not the intention of the use of moxa but is possible. Cupping can leave red raised round marks that bruise and remain up to 14 days. _____-initial

If I have any concerns I will speak with Leslie Gray before or after my treatment. If during my treatment I do not feel comfortable I will inform Leslie Gray immediately. _____ initial


Signature: _________________________________________________________________________