Patient Intake Form

Doctor Information Doctor's Name Clinic Phone Residential Phone Cell Email

Patient Information Patient ID Date First Name Surname Age Father/Husband's Name Sex: Male Female Profession Address Phone Email Height Weight Habits Diet: Veg Non-Veg Disease

Summary and Chief Complaints 1. Chief Complaints 2. When did the problem begin? 3. Aggravates / Improves 4. Worst Time of Day 5. Accompanying Symptoms

General Questions 6. Environment Comfort/Distress 7. Most Uncomfortable Position 8a. Chilly or Warm? 8b. Perspiration (when, where, odor, stains) 9. Tongue Description

Mental / Emotional 10. Worries and Coping 11. How do you keep your surroundings? 12. Crying (ease & situations) 13. Coping when upset 14. Anger (triggers & reaction) 15. Predominant emotions 16. Fears 17. Difficult circumstances & coping 18. Greatest joys 19. Childhood 20. What bothers you most in others 21. Problems in relationship 22. Recurring dreams 23. What do you need to be happy? 24. Work & ideal job 25. If President for a day 26. Criticism & Praise received 27. What would you change most about yourself?

Food 28. Feelings before/during/after meals 29. Food you most want 30. Foods you dislike/react badly 31. Drinks/day, thirst, temp preference

Sleep 32. Sleep quality 33. Actions during sleep 34. Trouble falling asleep/waking

Women (If applicable) 35. Pregnancies / Children / Miscarriages / Abortions 36. Age menses began / menopause 37. Frequency of menses 38. Duration, abundance, color, odor 39. Feelings before/during/after menses

Health History 40. Current medications 41. Frequency of colds/flus 42. Childhood illnesses (severe/recurrent) 43. Vaccinations & reactions 44. Surgeries (what & when) 45. Warts, cysts, tumors (details) 46. Discharges (color, consistency)

Sensitivity 47. Need smaller medication doses? 48. Anesthesia (effects) 49. Reaction to vitamins/herbs 50. Life timeline (birth to present) 51. How do you feel standing in line? 52. Reaction when family sick 53. Sexual energy 54. Reaction to consolation 55. Most difficult part of life 56. Hobbies & travel desires 57. Anything else to add 58. Read carefully and fill only applicable fields.