Free Range Acupuncture Confidential Intake Form

Name______________________________ Date________________Email_________________________________

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Recommendations:!�1

Why are you here today? How are you feeling compared to the last time you were here? !

How does your body feel ?

Draw it!

Notes!

Free Range Acupuncture Confidential Intake Form

Energy & Emotions I have been having trouble with: (Circle all that apply) !

Anger Irritability Sensitivity Outbursts Worry Racing or-Repeating Thoughts Poor Memory Hyperactivity Anxiety Difficulty Concentrating Fatigue Sadness Depression Grief Boredom Isolation !

Sleep I sleep____hours per night.

I have difficulty w/: Vivid Dreams Falling sleep / Staying asleep/Getting up !

!• What do you do to Relax & Have Fun? !!!• What Practice, Image or Story calms & centers you? !!!• How’s your Energy? Too little/Enough/Too Much/ Uneven !!! !• What is your Primary Concern today - the main

thing that you want to work on improving?

Recommendations:!�2

Free Range Acupuncture Confidential Intake Form Please circle all of the following symptoms that apply: This / That !Headaches What are they like? !Recent / Recurrent & Chronic Sharp / Dull / Throbbing/Dizziness

!When are they? !Morning / Noon / Evening

!Where? !Back of Head/ Neck Forehead/ Temples Sides of head/ Top of head Whole head/ Behind Eyes

!

Aches, Pains or Numbness

Where is the primary area? Type: Ache/Pain / Numbness Whole Body Chest / Abdomen / Ribs/ Hips Shoulders /Hands/Arms/Elbows/ Hips/Knees/Feet Back: Upper/ Mid/ Lower

!What’s the pain like? !Sharp / Stabbing / Dull Throbbing/ Cramping Heavy / Swollen/ Radiating Feel to touch: Hot / Cold/ Numb

!Rate Discomfort 1-10:_______ !What makes the pain better?

Pressure / Heat / Cold Rest / Activity / Eating

!

Digestion, Food & Tastes

My relationship with food: !No appetite / Excessive Appetite Bingeing/ Cravings for - Sugar? Salt?/ Other:_________________

!I have trouble with: !Indigestion /Belching / Bloating / Gurgling Nausea / Vomiting / Ulcers Acid regurgitation / Heartburn Hernia / Severe Stomach Pain

!After Eating I feel:

My Best / Bad / Tired Pain !Taste in Mouth: Bitter/ Sweet / Sour / Salty / Pungent / Spicy

Recommendations:!�3

Free Range Acupuncture Confidential Intake Form I like Drinking:

Hot drinks / Cold drinks/ with ice # ____Caffeinated drinks/day #____ Alcoholic drinks/week

Problem for you? Caffeine/Alcohol !Bowels & Urination

Generally: Constipation / Diarrhea Alternating / Pain with Pooping !My poop looks: !Formed / Loose /Pebble/Bloody

with: Undigested food /Mucus !Daily Bowel Movements (BM):

1-2 BM per day/ More/ Fewer !Urination:

Frequent/ Leakage/ Pain I wake to pee_____times/night

!

Frequent Infections What kind?____________________

Throat or Chest/ Ears/ Sinus/UTI

!Eyes, Ears & Nose

I experience:

Ringing in ears/ Floaters in eyes /

Shortness of Breath Allergies: Itchy eyes, ears, nose

Sinusitis / Stuffy or drippy nose / clogged or constricted throat

!Skin&Hair

I have difficulty with: Eczema / Psoriasis / Acne Itching / Rashes / Hives/ Dryness Hair: Premature greying / Hair Loss

Women Last Period:___________________ # of Days flow__________

Women cont. The blood is: Bright/Dark/Pale with: Clots / Cramping / Bloating !Before period: Sensitivity/ Breast Tenderness Discharge Yeast infections !Men Trouble with Erections Pain in Testicles / Hernia Inflamed Prostate Anything else:___________________

!Sexuality I’m having a difficult time with: Physical Function/ Desire/ Pain Energy/ Partner(s) /Attitude !!!

Recommendations:!�4

Free Range Acupuncture Confidential Intake Form

Past Medical History Please describe any significant injuries, surgeries, major illnesses whether you were hospitalized or not? !!!!!!!!Women Are you presently pregnant or trying to get pregnant?Pregnant/ Trying / Neither Past Pregnancies_______ Miscarriages ________ Abortions________ !Supplements/ Medications/Herbs Include what you are using them for: !!!!Recreational Drug use Marijuana: Daily/ Weekly/ Problem for you? Little/ Big Coke: Daily/Weekly/ Problem for you? Little/Big Other:______________________Daily/Weekly/Monthly

!Have you had any of these conditions? When?

PLEASE ADD DATE (EST. OK) •Frequent Childhood Illnesses •HIV/ AIDS •Alcoholism •Drug Addiction •Asthma •Birth Trauma (your own) •Cancer •Diabetes •Emphysema •Heart Disease •Hepatitis A/ B /C •Herpes •Lyme Disease •Multiple Sclerosis •Pacemaker •Polio •Rheumatic Fever •Scarlet Fever •Seizures •Tuberculosis •Latex Allergy •Lymph Nodes Removed •Tonsils Removed •Hysterectomy •Anything else removed:______________________ Other:_____________________________________

Recommendations:!�5

Free Range Acupuncture Confidential Intake Form

ATTUNMENT NOTES NAME:__________________________________ DATE:________________

Recommendations:!�6

Free Range Acupuncture Confidential Intake Form

� � TONGUE Pulse ! HT/SI LU/LI ! LV/GB SP/ST ! KD/UB PC/TH

!Circuit & Elements

Pattern of Fatigue LU LI ST SP` Spinal Irritation HT SI UB KD Diaphragm Constriction PC TH GB LV Cardiac Alarm Pelvic Collapse Fire Next Steps: Wood Earth Treatment Principle ! Metal ! Water

Points Muscles

Recommendations:!�7

!Palpation