CONFIDENTIAL PATIENT INTAKE FORM

First Name

Middle Name

Last Name

Marital Status

Married

Single

Widowed

Divorced

Birth Date

Age

Height

Weight

Your Gender

Address

City

State

Postal code

Country

Phone

Email

Employment Status

Employed

Self-Employed

Unemployed

Retired

Occupation

Emergency Contact (nearest person NOT living with you):

Whom can we thank for referring you?

YOUR HEALTH HISTORY & CURRENT INFORMATION

1. What is the principal complaint for which you are seeking my care?

2. List in order in severity (most severe first) any and ALL health problems which bother you.

3. List any chronic health problems you’ve had which appear to be resolved.

4. List any present problems which you have accepted as part of your life.

5. List the doctors or practitioners you have seen for the above conditions.

6. List any accidents or injuries you have had, and when they occurred.

7. List any surgeries you have had giving dates where possible.

8. List any prescription medications or over-the-counter (eg. TUMS, Tylenol, Mylanta, etc.) drugs you have taken in the past, and for what length of time.

9. List prescription medications or over-the-counter drugs you presently take.

10. Do you take any herbs, vitamins or homeopathic medicines?

If you answered yes to any of the above, please list names below:

11. (Women) Do you feel you have menstrual or menopausal problems? Describe.

12. (Women) Do you now or have you in the past taken birth control pills?  If yes, please indicate when, and for how long.

13. How would you describe your elimination; specifically:

Do you frequently experience loose stools?

Yes

No

Do you frequently experience constipation?

Yes

No

Do you have bowel movements daily? If yes, about how many? If no, about how often? Please provide any other relevant details about your elimination:

14. In your own estimation, how do your kidneys and bladder function?

15. In your opinion, do you have weak or sensitive lungs? Please describe:

16. Do you or members of your family have history of heart problems?

ENVIRONMENTAL/DIETARY EXPOSURE

17. Which type of water do you primarily drink?

18. Do you live close to a freeway or other heavy traffic area?

Yes

No

19. Do you eat shellfish (shrimp, lobster, crab, scallops, etc.) regularly? If yes, which and about how often?

20. Do you use aluminum pans? If no, have you used them in the past?

Do you use commercial body deodorants/anti-perspirants that contain aluminum?

Yes

No

21. How often do you eat:

Chocolate?

Wheat?

Spicy foods?

Ice Cream?

Refined sugar?

Dairy?

Pastries?

22. Do you drink carbonated “soft drinks”?   If yes, how much per week?

23. Do you smoke? If yes, how much?

24. Do you drink coffee? If yes, how many cups per day?

Do you drink alcohol? If yes, indicate about how many per week of the following:

Beers
Glasses of wine
Striaght or mixed drinks

25. Are you exposed to chemicals or fumes in your work environment? If yes, please describe:

26. Have you been exposed to new carpet, paint, or a new car recently? If yes, please describe:

27. Please describe your typical meals and snacks:

Breakfast
Lunch
Dinner
Snacks

28. How often do you use a cell phone? How often do you use cordless phones? Do you work on a computer? If yes, how often & for how long?

29. Do you have regular exercise/sports/hobbies & describe:

30. Have you ever had acupuncture before? If so, did it seem to help your condition? Or, Did it seem to aggravate your condition?

31. Have you ever had x-rays before? If yes, when and for what?

32. When was the last time you had lab work performed, and for what?

33. Have you ever used recreational drugs? If yes, which ones?

34. Do you have breast implants or prostheses? If yes, please describe.

LIFESTYLE

35. Your favorite season? Least favorite season?

36. Most energized time of day? Least energized?

37. Describe how well you sleep, including how many hours: Do you find it difficult to fall asleep? If you wake in the middle of the night, do you have difficulty falling back to sleep?

38. Do you exercise? What do you do and how often?

39. Do you meditate? If so, how often?

40. Have you ever done a dietary and lifestyle cleanse program? Please describe details.

41. What are your top 5 reasons you want to feel better?

1.
2.
3.
4.
5.

42. Did you get Covid? If so when? Was it mild, moderate or severe

43. Did you get the Covid vaccine? If so, how many? Do you have any ongoing symptoms that you feel are related to either Covid or the vaccines?

44. If you were referred to the Healing Essence Center by a friend or family member, please provide their names and contact information so we may thank them.

Digital Signature (Full Name)