Form | Indigo Sun

Client Intake Form

631 Birch Street, Unit D, Windsor, CO 80550 - (970)213-6331

Date: __________________

Name: _________________________________________________________________________________________________________________________________

First Middle Last

Address: ______________________________________________________________________________________________________________________________

Street City State Zip

Home Ph #: _____________ Business/Cell #: _____________ Email: ______________________________________________________________________

Age: ______ Date of Birth: _____ /_____ /______ Gender: M F Height: ________ Weight: ________

MM DD YY

Marital Status: S M D W Number of Children: _____ Occupation: ______________________________________________________________

Employer:______________________________________________________________________________________________________________________________

Primary Care Physician: _______________________________________________________________________________________________________________

Physician's Ph #: ____________________________ Last Physical Exam Date: ________________________________

Emergency Contact: ___________________________________________________________________________________________________________________

Name Relation Phone #

Referred by: ___________________________________________________________________________________________________________________________

Heath Insurance

Insurance Company: ___________________________________________ Provider #: _______________________________________________________

Member ID #: ________________________________ Group #: ________________________________

Primary Cardholder's Name: __________________________________ Date of Birth: __________________________

Person Medical History (surgeries, hospitalizations, illness, diseases, accidents and dates):

_________________________________________________________________________________________________________________________________________

Contagious diseases:

_____ None _____ HPV _____ Herpes _____MRSA _____AIDS _____ Hepatitis (A,B,C,D)

_____ STDs _____Other________________________________________________________________________________________________________________

Allergies: ______________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

Medications & Supplements (herbs & vitamins) you are taking or have taken in recent past:

_________________________________________________________________________________________________________________________________________

Family Medical History (parents, grandparents, sibilings, children):

____ alcoholism _____ allergies _____ arthritis _____ asthma _____stroke

____ drug abuse _____ epilepsy _____ eye disease _____ heart disease _____TB

____ kidney disease _____ liver disease _____ mental health _____ sinus problems

____ spine problems _____ diabetes _____ high/low blood pressure

Age Parents Died: _____ Mother _____ Father

Present Illness:

What is your chief complaint?_________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

Date this condition began? _________________

How did this condition begin?_________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

What treatment have you received for this condition?________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

Effectiveness of treatment received?__________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

What makes it better?_________________________________________________________________________________________________________________

What makes it worse?__________________________________________________________________________________________________________________

Lifestyle Habits:

____black tea ____coffee ____chewing tobacco ____ alcohol ____soft drinks

____cigarettes ____sugar ____ recreational drugs ____ salt ____other ______________________________________________________

Exercise:

____ never ____occasional ____ moderate ____ heavy

Type of Exercise: ______________________________________________________________________________________________________________________

Emotions:

____happy (excess/deficient) ____worry ____anxious/restless ____controlling

____fear ____over thinking ____stubborn ____sadness/grief

____cry easily ____aloof ____poor willpower ____reckless

____angry/irritable ____depression ____other _________________________________________________________________________________

Energy:

____normal ____low ____excess ____low after eating ____low in afternoon

____more energy at night ____variable ____other____________________________________________________________________________________

Weight:

____normal ____underweight ____overweight

____recent gain (how much?____ ) ____recent loss (how much?____ )

Appetite:

____variable ____poor ____good ____excessive ____hungers rapidly ____loss of taste

____other ______________________________________________________________________________________________________________________________

Diet (describe a typical meal):

breakfast: _____________________________________________________________________________________________________________________________

lunch: _________________________________________________________________________________________________________________________________

dinner: ________________________________________________________________________________________________________________________________

cravings? ______________________________________________________________________________________________________________________________

Do you eat 3 meals a day?______ Do you eat a regular hours?______ Do you eat late at night?______

Digestion:

____normal ____heartburn ____belching/burping ____gas ____bitter taste

____nausea/vomit ____nervous stomach ____bloating ____bad breath ____gallstones

____stomach noises ____hiccups ____indigestion ____full feeling or distention

____abdominal pain/cramps ____difficulty digesting fatty/oily foods ____food doesn't descend

____other ______________________________________________________________________________________________________________________________

Bowels:

____ normal ____loose stool ____ black stool ____ burning anus

____ diarrhea ____ constipation ____hemorrhoids ____colon problems

____ hard stool ____ anus itch ____ blood in stool ____stool w bad smell

____ pain/cramps ____ small stool amount ____laxative use ____mucous in stool

____intestinal worms ____ undigested food in stool

____alternating constipation & diarrhea/loose stool ____other _____________________________________________________________________

Urination: (4-6x per day is normal)

____normal ____burning ____dribbling after urination ____bladder infections ____urgency

____frequent ____blood ____bladder infections ____pus/infections ____profuse

____cloudy ____strong smell ____abnormal color ____night time ____painful

____scanty ____kidney stones ____other__________________________________________________________________________________________

Body Temperature:

____normal ____warm natured ____feel warmer in late afternoon & night

____cold natured ____warm palms ____cold hands & feet ____warm soles

____cold lower body ____warm upper body ____flushed face ____alternating chills & fever

____other________________________________________________________________________________________________________________________________

Perspiration:

____normal ____ profuse ____small amounts ____head

____chest ____ palms ____feet ____bad smell

____oily ____night sweats ____hot flashes ____without exercise

____other_________________________________________________________________________________________________________________________________

Thirst:

____normal. ____less than normal ____excessive ____prefer hot drink

____prefer cold drink. ____increased thirst at night ____thirsty but do not drink

____other ________________________________________________________________________________________________________________________________

Sleep:

____normal ____vivid dreams ____difficulty falling asleep ____difficulty going back to sleep

____restless ____sleep too much ____awake tired in morning ____wakes easily ___nightmares

____other_________________________________________________________________________________________________________________________________

Headaches/Dizziness:

____headaches ____dizziness ____ poor balance ____ motion sickness

____heavy headed feeling ____migraines ____vertigo ____ poor memory

____fainting ____dizzy w changes in position ____ other ________________________________________________________

Skin:

____normal ____eczema ____boils ____body odor

____oily ____slow to heal ____ulcers ____moles

____clammy ____dry ____itching ____warts

____bruise easily ____hives ____acne ____yellow skin

____rashes ____other ____________________________________________________________________________________________________________

Hair:

____normal ____oily ____dandruff ____falling out ____dry/brittle ____prematurely grey

____other_________________________________________________________________________________________________________________________________

Nails:

_____normal ____spots ____grow slowly ____grow rapidly ____brittle/break easily

_____purple ____soft ____pale ____ridged/lines ____other__________________________________________________________________

Eyes:

_____ normal _____ eyelids swollen _____ blurry vision _____red

_____ need glasses/contacts _____ tearing _____ inflammation _____ glaucoma _____dry _____ spot/lines in vision

_____ itching _____ poor night vision _____ failing vision _____ pain

_____ pale under eyelids _____ twitching _____ stymy history _____ cataracts _____ strain

_____ macular degeneration _____ blinking _____ color blindness _____ light sensitivity

_____other ________________________________________________________________________________________________________________________________

Ears:

____ normal _____ discharges _____ poor hearing

____ ear aches/pain ____ ringing (high/low pitch) _____ itching

____ infections ____whooshing sound

____ other _______________________________________________________________________________________________________________________________

Nose:

____normal ____allergies ____sneezing ____environmental

____congestion ____overly dry ____rhinitis ____sinusitis

____bleeding ____ post nasal drip ____nasal sores ____nasal polyps

____mucous ____loss of smell sensitivity ____structural issues

____other _________________________________________________________________________________________________________________________________

Mouth & Throat:

____normal ____difficulty swallowing ____mouth/tongue sores ____dry/cracked lips ____drooling ____lump in throat feeling

____tonsillitis ____ grind teeth ____ swollen glands ____ dry mouth/throat

____teeth problems ____ gum problems ____TMJ ____thyroid problems _____hoarseness ____frequent sore throat ____other__________________________________________________________________________________________________________________________________

Respiratory:

____normal ____difficult inhalation ____difficult exhalation ____dry cough

____frequent sighing ____asthma ____excess coughing ____shortness of breath

____chest pain ____cough with phlegm ____bronchitis ____frequent colds

____cough with blood ____lung cancer ____emphysema/COPD ____on oxygen

____tightness in chest ____difficult breathing when lying down ____other_______________________________________________________

Cardiovascular / Circulation:

____normal ___ palpitations ____high cholesterol ____low cholesterol

____numb/tingling limbs ____murmur ____bleed easily ____bleeding disorder

____varicose veins ____diagnosed heart problem ____anemia ____blood clots

____slow heart beat ____high blood pressure ____low blood pressure ____chest pain

____bruise easily ____purple hands/feet ____irregular heart beat

____swelling (ankles, hands, face)

other: ____________________________________________________________________________________________________________________________________

Pain:

Where are you feeling pain in your body: _______________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

What makes the pain worse? ____________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

What makes the pain better? ____________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

Any other problems you would like to discuss? __________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

FOR MALES ONLY:

_____reduced sex drive _____ impotence _____ genital pain _____dribbling after urination

_____sperm problems _____ hernia _____ prostate problems _____pain/burning with urination _____ seminal emissions _____discharges _____ premature ejaculation

____other_________________________________________________________________________________________________________________________________

Men, you have completed this form. Thank you!

FOR FEMALES ONLY:

Are you pregnant? ____Yes ____No

If yes, what is the approximate date of conception? _____________________________________________________________________________________

What method of birth control do you currently use? ____________________________________________________________________________________

What method of birth control have you used in the past? _______________________________________________________________________________

Do you have regular PAP tests? ____Yes ____No

Do you have regular breast exams? ____Yes ____No

Do you have breast implants? ____Yes ____No

Do you have excess facial/body hair? ____Yes ____No

Do you have a reduced sex drive? ____Yes ____No

Menstrual Cycle:

Age started? _______ Days of flow? _______. Age stopped? _______

How many days from the beginning of your period to the beginning of the next one? __________________________________________________

Check all that apply:

____irregular ____heavy flow ____scanty flow ____dark flow color (dark red, purple)

____clotting ____no menses ____water retention ____ light flow color (light red, brownish)

____sighing ____ pain/cramps ____skin eruptions ____lump in throat feeling

____backache ____breast lumps ____abdominal bloating ____painful/tender breasts

____mood swings/changes ____constipation or diarrhea

____other_________________________________________________________________________________________________________________________________

Discharges:

____thick ____white ____ yellow ____clear ____ itching ____yeast infections

____blood ____none ____bad odor other________________________________________________________________________________________

Pregnancies:

Total number?______ Number of children?______

Number of abortions?______ Number of miscarriages? ______

Any pregnancy or childbirth complications? (explain) ___________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

Menopause:

____hot flashes ____dizziness ____night sweats ____anxiety ____memory problems

____fatigue ____poor sleep ____ palpitations ____tinnitus ____mental restlessness

____backache ____feel cold ____cold feet ____irritable ____frequent urination

____dry mouth ____N/A ____ other _______________________________________________________________________________________

Any other gynecological concerns? ______________________________________________________________________________________________________

Women, you have completed this form. Thank you!

Informed Consent

I hereby request and consent (or provide consent for the patient named below for whom I am legally

responsible) to the performance of acupuncture and other procedures within the scope of practice of

Traditional Chinese Medicine by the acupuncturist named below and/or other licensed acupuncturists who

may in the future treat me while employed by, working or associated with, or serving as back-up for the

acupuncturist named below, including those working at the office/clinic listed below, whether signatories

to this form or not.

I have had an opportunity to discuss with the acupuncturist named below (and/or with other office/clinic

personnel) the nature and purpose of acupuncture and adjunct therapies (tui na, auriculotherapy,

moxibustion, cupping, bleeding, gwa sha, dietary and lifestyle instruction).

I understand that the therapies provided through Traditional Chinese Medicine are not to be considered a

substitute for Western Medicine nor are these therapies be construed by the client to be a diagnosis or

treatment of any disease or injury.

I understand and am informed that, as in the practice of medicine, in the practice of acupuncture and

adjunct therapies, there are some risks to treatment, including but not limited to nausea, light headedness,

fainting, bruising, hematoma, nerve damage, skin irritation or burn, a punctured lung or organ, and

infection. I do not expect the acupuncturist to be able to anticipate and explain all risks and complications,

and wish to rely on the acupuncturist to exercise judgment during the course of the procedure which the

acupuncturist feels at the time, based upon the facts then known, is in my best interests.

I HAVE READ OR HAVE HAD READ TO ME THE ABOVE CONSENT. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE TO THE ABOVE NAMED PROCEDURES. I INTEND THIS CONSENT FORM TO COVER THE ENTIRE COURSE OF TREATMENT OF MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK TREATMENT.

To be completed by the patient or patient's representative

(if patient is a minor or physically/legally incapacitated)

X______________________________________________ INDIGO SUN ACUPUNCTURE

Patient’s Name - PRINT Ellen B. Williams, L. Ac., Dipl. Ac.

631 Birch Street, Unit D

X_____________________________________________ Windsor, CO 80550

Patient / Representative's Signature Phone: (970)213-6331

Fax: (970) 800-3480

X ____________________________________________

Date Signed