Introductory Medical Intake Form

Patient Name:                                                                 Age:                         Date…………………..

1.     Main Complaint:……………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………

Length of time?.............................................................................................................

What conditions alleviate the symptoms?....................................................................

What conditions worsen the symptoms?.......................................................................

Western Diagnosis?.....................................................................................................

Western Medications:……………………………………………………………………………………………

Past Surgery?..............................................................................................................

Short medical related history…………………………………………………………………………………..

……………………………………………………………………………………………………………………………………

1..     Physical Pain,location:……………………………………………………………………………………………….

Sharp	Dull	Pricking	Fixed/static	Moveable
Radiating	Oppression	Soreness	Weakness	Tightness

3.Muscle cramping, locations/frequency:…………………………………………………………………….

4.     Tremors locations/frequency:……………………………………………………………………………………

5.     Skin disorders Location:……………………………………………………………………………………………

6.     Abnormal Sweating Condition:

Sweating after eating

Spontaneous sweating

Excessive sweating

Night sweating

Lack of sweating

Location:…………………………………………………………………………………………………………………..

7.

.Aversion to Wind	Aversion to Cold	Aversion to Dampness	Aversion to heat
Dislike of air condition or drafts	Dislike cold inside or outside	Dislike Damp or rainy weather	Dislike summer and can’t stand the hot weather

8     Subjective feeling of the body and limbs:

The Body feels:

Freezing

Cold

Normal

Warm

Hot

 9.Upper Limbs feel: (hands and/or arms)

Freezing

Cold

Normal

Warm

Hot

10.Lower Limbs feel:

Freezing

Cold

Normal

Warm

HOt

11.     Cough and Wheezing:

Dry cough	Profuse phlegm	With scant phlegm	Easy to expectorate	Hard to expectorate
Difficult to lie down	Yellow phlegm	White phlegm	Foaming	Excessive salivation

 12.     Dryness:

Mouth

Throat

Eyes

Nose

Ears

13.     ENT:

Blurry vision14	Poor Vision	Floaters	Photophobia
Blocked sinus	Runny nose	Sneezing	Postnasal drip
Tinnitus	Deafness	Poor hearing	Ear pain
Mouth ulcers	Painful gums	Gum ulcers	Tongue pain

  14   Taste in Mouth:

16Neutral	Bitter	Salty	Sweet
Metallic	Sticky	Unclean	Abnormal

15Thirst:

Not thirsty	Thirsty for cold drinks	Thirsty for warm drinks	Thirsty but doesnt drink
Drinking causes bloating	Drinking causes nausea	Drinking does not quench thirst	Thirst at night
Drinking Habits:	4-5 cups a day	Less than 4 cups a day	More than 8 cups a day

16.  Appetite:

Good appetite	Low appetite	No appetite	Big Appetite
Bloating after eating	Pain after eating	Gas after eating	Glomus after eating

Three meals a day	Two meals a day	One meal a day	More than 3 meals a day
Big Meals	Small meals	Snacks only	Smoothie only
Vegan	Vegetarian	Paleo	No restriction
Food Allergies?	What type:
Common Diet	Breakfast	Lunch	Dinner
List items:
List supplements:

17.  Abdominal Pain

Upper Abdomen5	Middle Abdomen	Lesser Abdomen	Whole Abdomen
Tensed pain	Stabbing pain	Distension	Dull pain

18.  Urine

Less than 4 times a day	4 to 6 times a day	Over 6 times a day/frequent	Night urination Yes/No? --- times
Painful	Urgent	Profuse	Scant
Dark Yellow	Light yellow	Clear	Red/pink
Interrupted	Smooth	Hesitant	Thin

19.  Stool: How often? Once/twice/three times?

Formed	Loose	Liquid	Dry	Sticky
Bloody	Difficult	Forceless	Incomplete	Painful

20.  Palpitations: Yes/No

Frequency

Duration

Day or Night

Painful

21.  Vertigo: Yes/No

Frequency

Duration

Day or Night

Need to sit?

22.  Sleep:

Good

Superficial/light

Deep

Poor

22a. Length:

Less than 2 hours

2 to 4 hours

4 to 6 hours

Over 6 hours

22b. Conditions:

Difficult to fall asleep	Wakes up easily	Dreamful	Wakes up tired
Interrupted due to pain	Interrupted due to thoughts	Interrupted due to urination	Interrupted due to ……………………

23.  General Emotions:

Happy	Content	Numb	Sensitive
Sad	Discontent	Depressed	Disconnected
Easily Irritable	Aggressive	Easily Angered	Emotional

Other:………………………………………………………………….

24.  Women’s Disorders:

Leucorrhoea	Profuse	Strong smell	Scant
Vaginal dryness	Vaginal itchiness	Vaginal pain	Vaginal sores
Low Libido	Excessive libido	Breast pain	Breast lumps
Uterine fibroids	Ovarian cyst	Thick endometrium	Pelvic pain

25.  Menstrual Conditions:

Regular	Irregular	Early	Late	Every … Months(2-6)
Painful lesser abdomen	Sore lower back	Pain radiating in the legs	Abdominal bloating	Soreness of the breast
Acne	Cold low back abdomen	Mood fluctuation	Spontaneous sweating	Low appetite or nausea

26. Bleeding Time

Bleeding less than 3 days

From 3 to 5 days

Bleeding over 5 days

Spotting

Non stop

25Blood Condition:

Red	Brown	Dark	Light
Scant	Profuse	With clots

26.  Male Disorders:

Prostatic fluid in urine	Scrotal itchng	Scrotal dampness
Scrotal pain	Perineal soreness	Excessive libido
Premature ejaculation	………/week, month	Low libido
Soft erections	Impotence	Duration:
Spermatorrhoea	……../week, month	Duration:
Infertility	Low sperm Motility	Low Sperm quality

27.  Are you Diabetic? Yes/No?

28.  Any Blood Pressure Problems? Yes/No. High Blood pressure/low blood pressure?

29.  Any Headaches? Yes/No.  Frontal/temporal/nape of neck or nape of head/all over?