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Acupuncture Intake Form
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First Name
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Your answer
Last Name
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Cell Phone Number (include area code)
*
Your answer
Email Address
*
Your answer
Spleen / Stomach
*
Excessive Appetite
Loose Stool / Diarrhea
Digestive problems / Indigestion
Vomiting
Belching, Burping
Heartburn / Reflux
Stomach Bloating
Obsession in Work
Blood in Stool
Lack of Appetite
Hemorrhoids
Easily Bruised
None of the Above
Required
Heart / Pericardium
*
Insomnia
Palpitations
Cold Hand & Feet
Nightmares
Mentally Restless
Laughing for No Reason
Chest Pain
Poor Memory
Sadness
Depression
Anxiety
None of the Above
Required
Lung / Large Intestine
*
Cough
Shortness of Breath
Decreased sense of Smell
Nasal Problems
Skin Problems
Claustrophobia
Colitis / Diverticulitis
Constipation
Allergies
Asthma
Get sick easily
None of the Above
Required
Kidney / Urinary Bladder
*
Low Back Pain
Knee Problems
Hearing Impairment
Ear Ringing
Kidney Stones
Decreased Sex Drive
Hair Loss
Urinary Problems
Dental Problems
Fatigue
Edema
None of the Above
Required
Liver / Gall Bladder
*
Eye Problems
Jaundice
Difficulty Digesting Oily Food
Gallstones
Light Colored Stools
Soft or brittle nails
Easily Angered
Difficult Relationships
Difficulty Making Decisions
Dizziness
Headaches
None of the Above
Required
*
I usually feel chilled
I usually feel warm
Neither
Required
Kidney Yin Deficiency
*
Lower back weakness soreness or pain
Ringing in Ears
Premature Grey Hair
Dark circles under eyes
Night Sweats
Hot Flashes
Afraid Frequently
Dizziness
Knee Problems
Vaginal Dryness
Lessened mid-cycle cervical mucus
None of the Above
Required
Kidney Yang Deficiency
*
Back sore or weak
Feet cold (especially at night)
Typically colder than those around you
Low Libido
Fearful
Early morning / late night frequent Urination
Frequent urination (dilute & large amounts)
Morning loose urgent stools
Low back pain pre-menstrually
Profuse vagina discharge
Cold cramps during your period that respond to a heating pad
None of the Above
Required
Spleen (Qi, Blood, and /or Yang Deficiency)
*
Often Fatigue
Poor appetite
Energy Low after a meal
Feel bloated after eating
Crave Sweets
Loose Stools, Abdominal Pain, or Digestive Problems
Hands & Feet cold
Prone to Feeling Sluggish
Prone to Heaviness or Grogginess in the head
Varicose Veins
Prone to Worry
Diagnosed with low Blood Pressure
Sweat a lot without exerting yourself
Feel Dizzy or Light-headed, or visual changes when you stand up fast
Often sick, allergies
Hypothyroid or Anemia
Hemorrhoids or polyps
Menstruation thin, watery, profuse or pinkish in color
More tired around menstruation or ovulation
Spotting a few days before period
Diagnosed with uterine prolapse
Menstrual cramps accompanied by bearing down sensation in uterus
None of the Above
Required
Blood Deficiency
*
Dry flaky skin
Chapped Lips
Brittle fingernails & toenails
Hair brittle or dry
Diminished night time vision
Lips, Tongue, & side of lower eye lids pale in color
Dizzy or Lightheaded around period
Losing Hair on head
Period light or late
None of the Above
Required
Blood Stasis
*
Periodic numbness of hands or feet especially at night
Varicose or spider veins
Red cherry spots on your skin
Chronic hemorrhoids
Dark spots in your eyes
Diagnosed with blood clotting disorder or vascular abnormality
Menstrual blood clots
Diagnosed with endometriosis or uterine fibroids
Piercing or stabbing menstrual cramps
Menstrual flow brown or black in color
Mid cycle pain around ovaries
Painful unmovable breast lumps
None of the Above
Required
Liver Qi Stagnation
*
Prone to Emotional Depression
Prone to Anger and / or Rage
Pupils dilated & large
Difficulty falling asleep at night
Experience Heartburn or wake up with bitter taste in mouth
Irritable pre-menstrually
Bloated & Irritable around ovulation
Ovulation last longer than it should
Breast sensitive or sore at ovulation
Nipple pain or discharge from nipple
Pre-menstrual breast distention or pain
Bloated premenstrual
Period Pain
Menstrual cramps in external genital area
Menstrual blood thick, dark, or purple
None of the Above
Required
Heart (Any Disorder)
*
Wake up early and have trouble getting back to sleep
Heart palpitations when anxious
Nightmares
Low in spirit or lacking vitality
Fidgeting
Prone to agitation or extreme restlessness
Sweat excessively, especially on your chest
None of the Above
Required
Excess Heat
*
Mouth & Throat usually dry
Often Thirsty for cold drinks
Feel warmer than those around you
Wake up sweaty or have hot flashes
Breakout with red acne, especially premenstrually
Short menstrual cycle
Vaginal Irritation
None of the Above
Required
Dampness
*
Feel tired and sluggish after a meal
Cystic or pustular acne
Urgent bright or foul smelling stools
Overweight
Wet slimy tongue
Body feel like a barometer (can you sense when it will rain)
Menstrual blood contain stringy tissue or mucus
Prone to yeast infection or vaginal itching
Fibrocystic breasts
None of the Above
Required
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