Eastern Center for Complementary Medicine

Eastern Center for Complementary Medicine

Intake Form

Please answer the following questions to the best of your ability to enable a more complete assessment of your condition and physical constitution.

Name:

Date:

Address:

City:State:Zip:

Daytime phone:

Home phone:

Sex:

Marital status:

Height:

Weight:

Birthdate:

Profession:

E-mail address:

Approximate birth time (if available):

Place of birth:

Referred by:

1. Please describe in detail the main problem(s) you would like to address. Include the onset, progression, aggravating and alleviating factors. How does this condition affect your life? Please rank your problem on a scale of 1 to 10 (where 1 is mild and 10 is severe):

1. On a scale of 1 to 10, how is your energy level (1 being the worst and 10 being the best)? Do you experience an energy slump at any particular time of day?

1. How is your urination? Do you experience any frequency, urgency, burning, dribbling? Do you notice any abnormal coloration? History of urinary tract infections or other urinary dysfunction?

1. How are your bowel movements? Are they regular, once a day, twice a day, every other day, etc.? Do you ever experience diarrhea, constipation, alternation of the two, etc.? Any history of large intestine problems?

1. Do you experience any sensations of hot or cold? Are you the type who prefers warmth, lots of sweaters and blankets? Or are you comfortable wearing T-shirts during colder weather?

1. How is your appetite?

1. Do you have any abnormal thirst, dry mouth or throat?

1. Do you have any night sweating? Sweating upon slight exertion?

1. How is your diet? Please describe in general what you eat. Do you eat a lot of sweets or any particular foods?

1. How is your digestion? Do you experience any bloating, reflux, gas, ulcers?

1. Do you have any known heart problems? Do you experience heart palpitations or fluttering?

1. Do you have any respiratory problems, history of asthma? Do you experience shortness of breath?

1. Do you have ringing in the ears, low or high-pitched? Stuffy sensation in the ears?

1. Do your eyes ever burn, itch or tear? Do they feel gritty or dry? Do you have floaters in your eyes?

1. How do you sleep at night? Do you fall asleep easily or have insomnia? Is your sleep continuous throughout the night? Do you wake up in the middle of the night and have difficulty falling asleep again? Do you wake up feeling rested? Do you have vivid dreams or nightmares? Do your dreams center around any particular themes and if so, what?

1. Do you have any propensity to catch colds or get sick?

1. If you smoke, consume alcoholic or caffeinated beverages, and/or engage in any other recreational drugs, please describe frequency and amount. If there is any history, please indicate below.

1. Please list all medications and supplements you are currently taking along with dosage.

1. Please list significant family history of disease (i.e. grandparents, parents, siblings).

1. For Females: Please describe your menstrual cycle (even if it has discontinued) in terms of cycle length, premenstrual and menstrual symptoms and severity (cramps, breast distention, mood swings, bowel changes, weight gain, etc.), color of blood (bright red, red, purple, pink), quality of blood (clots, thick, thin, etc.). If you are menopausal or postmenopausal, please describe symptoms (hot flashes, sleep disturbances, mood swings, etc.).

1. Please list all injuries or hospitalizations you have ever sustained and approximate when they occurred in order. This allows us to establish any causal links between prior injuries and your current complaint. It is important that you list every injury you can think of. Be sure to include: broken bones, stitches, scars, vaccinations, surgeries of any sort and any other traumatic injuries (physical or emotional such as car accidents or a divorce) even if you don’t think it is related.

1. Please list all major emotional events in your life and approximately when they occurred. Please list any emotional events, whether or not you think they are major, that occurred within 6 months of the onset of your chief complaint. If there was an event but you do not want to disclose it, please indicate that and the approximate date.

1. How often have you taken antibiotics?

1. How often have you taken oral steroids?

1. Childhood:

1. Do you have mercury amalgam fillings? Have you had any in the past? Have you had any root canals or other major dental work?

1. Please describe any expectations you have of us or particular limitations you would like for us to consider. Some examples have included: expectations that your condition should be resolved within a certain number of treatments; particular things you want or do not want such as herbal medicine, dietary recommendations, needles, no needles in the face, etc.

1. Please add anything else you feel we should know about:

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