Acupuncture & Natural Therapies/ Melanie Myers

O.M. Patient Intake
General Q and A

O.M. Patient Intake Form



Chills and fever:
Do you have chills and fever?____________________________________________________
When do they occur?___________________________________________________________
Check what applies:
1. Simultaneous chills and fever(_)
2. Chills predominant (_)
3. Fever predominant (_)
4. chills without fever (_)
5. fever without chills (_)
6. slight fever occurring at a definite time of day (_)
7. alternating chills and fever (_)
8. constant fever that rises during the evening (_)
9. Fever rises during the night (_)
10. irregular periods of low fever and lassitude(low energy) (_)
11. chills or cold limbs (_)

Do you perspire? (_)
Perspire after heavy or slight exertion? (_)
Any odors with perspiration? (_)
Do you perspire at night? (_)
Do you perspire spontaneously/easily? (_)

Food and Drink/Appetite, Thirst and Taste:
How is your appetite? _________________________________________________________
Any changes recently?_________________________________________________________
Weight gain (_) or loss (_)?
How is you thirst?_____________________________________________________________
Prefer hot (_) or cold (_) drink?
Any food craving?_____________________________________________________________
Any feeling of fullness after a meal?_______________________________________________
If so, where?__________________________________________________________________
Any unusual tastes in your mouth?________________________________________________

Defication and Urination:
Do you get constipated (_) or have diarrhea (_)?
How many times a day do you urinate (______) have a bowel movement?(_____)
Is your urine scanty(_)or profuse(_)?
Is the color of urine clear(_), yellow(_), dark(_) or cloudy(_)?
Any pain or difficulty?__________________________________________________________
What is the consistency of your stools? Dry(_) soft(_) loose(_) wet(_)
Any undigested food (_), mucous(_)or blood(_) in the stool?

Pain(head/body, chest/abdomen, eyes/ears):
Where is your pain?____________________________________________________________
Is it fixed(_)or does it migrate(_)?
Is it relieved(_) or aggravated(_) by pressure?
Relieved by hot(_) or cold(_)?
Does it come and go?__________________________________________________________
Any Headaches?______________________________________________________________
Any specific time of day or night that it is worse or better?_____________________________

Do you sleep well?____________________________________________________________
How many hours?_____________________________________________________________
Do you have trouble staying asleep?_______________________________________________
Any trouble getting out of bed in the morning?_______________________________________
Any recurring dreams or nightmares?______________________________________________

What emotion do you tend to favor most? Circle one
: Fear(k) Anger(Lr) Joy(H) Sadness(Lu) Worry(S)

Check any ongoing Problems:
Hot hands/feet(_) cold hands/feet(_) Energy level good(_) poor(_) dizziness(_) Cravings(_) sorethroat(_) dry throat(_) teeth problems(_) nose bleeds(_) sinus problems(_) Headaches(_) bleed or bruise easily(_)
Digestive(_) hemorrhoids(_) bloody stools(_), black stools(_) gas(_) bloating(_) Pain(_) where?_________
Bad breath(_) belching(_) ulcers(_)
Cardiovascular: HBP(_) LBP(_) Chest Pain(_) Irregular heartbeat(_) blood clots(_) fainting(_)
difficulty breathing(_) swelling of hands/feet(_)
Respiratory: cough(_) coughing blood(_) trouble breathing(_) asthma(_) short of breath(_)
Genito-urinary: pain on urination(_) Frequent urination(_) Blood in urine(_) urgency to urinate(_)
Unable to hold urine(_) kidney stones(_) venereal disease(_) impotency(_)
How often at night? (___)
Musculoskeletal: Neck pain(_) muscle pain(_) back pain(_) joint pain(_)
Other joint or bone problems:______________________________________________________
Neurosychological:seizures(_) areas of numbness(_) Poor memory(_) concussion(_) Depression(_)
anxiety(_) bad temper(_) easily stressed(_) treated for emotional or psychological problems?(_)

Habits: cigarettes(_) coffee(_) tea(_) alcohol(_) drugs(_) sugar(_) salt(_) other(_____________)
Menses and Leukorrhea(Females Only):
Number of pregnancies(_) # of births(_)
Is your period the same time each month?___________________________________________
How far apart is your cycle? (time between periods)__________________________________
Is your flow heavy(_) or light(_)?
What color is it?_______________________________________________________________
Any clots? (_) Pain?(_)
Do you have or have you had vaginal discharge? (_)
What is the consistency, color and odor?____________________________________________

Acupuncturists Notes: (observation/(Inspection, palpation)

Pain scale:1-10(now, and at worse time)
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10

Pulse=Rt. Lung Lt: Heart
Spleen Liver
Qi Kidney

Tongue=Body: Coat:
Thickness and moisture, and other features:
Sparkle in eyes:
Responding:(keen or dull):
Geographical Features noted:
Texture of skin:
Skin Color:
Head appearance:development, fontanelle(collapsed or raised)
Hair appearance: falls out easily or falls out suddenly in clumps
Ear: dry, color, pus, Lobes(full, beefy or pendulaous?)
Nose: Nostrils move, dry,red, white, shiny white
Eyes:Bright, stiff, red sclera, unclear sclera, purplish sclera, excessive tears, sand in eyes without red, wide pupils, fear of bright lights, gray and baggy eye sockets, protruding eyes.
Lips:Pale-white,reddish,dry,blue/breen, purplish, chapped, cracks, trembling, excess salivation, mouth askew, cannot close mouth.
Teeth: dry teeth or gums, red swollen or hot gums, teeth look like dry bones, grinding teeth
Throat: swollen,re and painful, swollen red, painful with ulcerations,chronic sore throat(not red), lump in throat.
Chin:Strong prominent, retronathic(forward),full-widebased jaw.
Skin: dry, damp,:itching,withered,swollen or pitting edema,pimples,boils, rashes(raised),redm moist dark rash, closed edged eruptions(do not lose color with pressure),Eruptions with pernicsious heat, many clusterd eruptions, eruptions do not occur with an illness that should have eruptions, red eruptions, reoccurring red eruptions without heat, eruptions with fluid, boils, ulcers not raised without color.
Body appearance:Overweight,thin, emaciated,agitated wouward, talkative, agreesive and irritable, passice, inward, quiet manner, heavy, ponderous,forcefulmovement, weak or frail movement,slow movements, curls up when lying, desires heat and overs up, lies stretched out or throws off covers and dislikes heat,paralysis of limbs,convulsions and deviation of eyes and mouth and twitching of muscles,
Arching the back and neck,
Speech: weak or low voice or faltering voice,lusty strong voice, stuttering, mutteringor extreme verbrosit, delirium, sudden loss of voice, rough and turbid voice, groaning and moaning outcries, weeping, singing, laughing, shouting.
Respiration:Shallow soft weak or shortness of breath, shallow breathing with sweating after exertion, rough and heavy, asthmatic wheezing: high rough sound with fircoed exhale, low troubled inhale.
Coarse breathing, asthma with rattle of sputum
Cough:cough with gurgling sounds, cough that is dry with little sputum, cough that is faint or feeble, cough with a coarce voice, cough with a clear voice.
Smell:offensive discharge,thick sputum with foul smell, dilute clear odorless sputum, scanty deepyeallow urine(offensive smell), clear odorless profuse urine, foul breath.

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Acupuncture & Natural Therapies/ Melanie Myers

Providing services in the following areas:
Fredericksburg, Virginia
Stafford, Caroline, Woodford, Thornburg,Spotsylvania, King George, Fallmouth, and more.

©2007 Melanie Myers, All rights reserved