Acupuncture Intake forms

COMMUNITY ACUPUNCTURE WEST .           Please know how it looks here is different than how it prints. 

New Patient Confidential Medical Intake Form

Name________________________ Home/Cell__________________ Date_____________


Date of Birth__________________ Occupation__________________________________

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 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   Dizziness    Ear infections   Eating Disorders   Emphysema   Emotional Changes   Fainting   Epstien-Barr   Epilepsy   Eye problems/watery/dryness/itchy Floaters   Fertility Issues   Fibroids   Fibromyalgia    Gallstones   Genital    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_ Sour_ 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   Indigestion   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   conditions. Watery   Floating   Undigested Food   No-Consistency   Bad Odor   Bloody/Black/Mucous   Alternates/Varies


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  N  Do 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   Stuck   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   

Check what you had, Circle conditions you have. Mark F on family medical conditions.

Burning   Constant   Cold   Hot   Pins and Needles   Tingling   Radiating   Tight  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 all the details!


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: _________________________________________________________________________