Confidential Patient Intake Form


Confidential Patient Intake Form

Your Name:

Marital Status: MarriedSingleWidowedDivorced

Spouse's Name (if Married):

Date of Birth:     Age:     Sex: MaleFemale

Height: Weight:

Mailing Address:

Home Phone: Cell/Mobile:

Work Phone:

Email Address:

Employment Status: EmployedSelf-EmployedRetiredUnemployed


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 used to have but which appear to be resolved.

4. List any present problems which you have simply accepted as part of life, due to the fact that you can’t see any way they’ll leave.

5. List the names of other doctors and/or other practitioners (acupuncturists, chiropractors, massage therapists, etc.) you have seen for the above conditions.

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

7. List any surgeries you have had (including in-office procedures) 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 any prescription medications or over-the-counter drugs you are presently taking.

10. Do you take herbs? YesNo
Vitamins? YesNo
Homeopathic medicines? YesNo
If you answered yes to any of the above, please list names below:

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

12. (Women) Do you now or have you in the past taken birth control pills? YesNo

If yes, please indicate when, and for how long.

13. How would you describe your elimination; specifically:

Do you frequently experience loose stools? YesNo

Do you frequently experience constipation? YesNo

Do you have bowel movements daily? YesNo

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?

City waterBottledFilteredDistilledSpring

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

19. Do you eat tuna fish or shellfish (shrimp, lobster, crab, scallops, etc.) regularly? YesNo

If yes, which and about how often?

20. Do you use aluminum pans? YesNo     If no, did you use them in the past? YesNo
Do you use commercial body deodorants/anti-perspirants that contain aluminum? YesNo

21. How often do you eat:

Chocolate? Popcorn? Ice Cream?
Spicy foods? Pastries?

22. Do you drink carbonated “soft drinks”? YesNo     If yes, which type? RegularArtificially sweetened
About how many per day? or per week?

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

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

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

1) Beers? 2) Glasses of wine? 3) Straight or mixed drinks?

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

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

27. Please describe your typical meals and snacks:

28. How often do you use a cell phone?
Daily/Multiple Times per DayCouple Times per WeekOnly OccasionallyRarely/Never

How often do you use cordless telephones?
Daily/Multiple Times per DayCouple Times per WeekOnly OccasionallyRarely/Never

Do you work on a computer? YesNo

If yes, how often & for how long?

29. Please indicate whether you have regular exercise/sports/hobbies & describe:

30. Have you ever had acupuncture before? YesNo

If so, did it seem to help your condition? YesNo

Did it seem to aggravate your condition? YesNo

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

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


Have you ever used recreational drugs? YesNo

If yes, which ones?

34. Do you have breast implants or prostheses? YesNo

If yes, please describe


35. Which is your favorite season? WinterSpringSummerFall
Your least favorite? WinterSpringSummerFall

36. What is your most energized time of day?
Your least energized?

37. Describe how well you sleep, including about how many hours per night:

Do you find it difficult to fall asleep? Often/AlwaysSometimesRarely

If you wake up in the middle of the night, do you have difficulty falling back to sleep?

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

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

40. Have you ever done a seasonal, dietary and lifestyle cleanse program? YesNo    If so, please describe, including: when, which cleanse program, how long, and whether it was helpful:

41. What are your top five reasons for wanting to feel better?

42. 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.

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