New Patient Form

First name

Last name

Age

Gender

Weight

Height

Phone

Please provide any underlying conditions if you have any. (i.e.: hypertension, diabetes, cholesterol, etc.)

What is your chief complaint?

What is the severity of your current condition from a scale of 1-10 (1: doesn’t affect daily lifestyle, 10: constant and unbearable)

What is the frequency of your current condition? Occasional? Intermittent? Frequent? Constant?

Briefly describe your current condition in detail.

Onset: When did it start? How did it start? What caused it to happen?

Location: Where is the affected area?

Duration: How long has it been going on?

Characteristics: Describe what you are feeling from the condition. Any side effects?

What aggravates the condition even more?

What alleviates the condition (if any?)

Has the condition gotten worse or has it improved any?

How is your sleep? Fall asleep fast and stay asleep? Hard time falling asleep? Describe in details if necessary.

How is your digestion? Bloated after eating? Gasey after eating or in general? Please provide any details that is of concern.

Do you experience any pain anywhere else in your body?

How is your normal emotional state? Are you stressed a lot? Depressed? Anxious?

Do you tend to get cold easily or hot easily? Do you prefer hot weather over cold weather or vice versa? Do you prefer to stay covered up or do you prefer to wear as little as you can?

Do you sweat a lot or not enough? Or is your sweating normal?

How is your stool? Do you go daily? Is it hard to excrete? The stool is hard or loose, or is it normal consistency?

How is your urination? Does output equal to input? Is it dark yellow, light yellow? Is there an odor? Do you have to go urinate frequently during the night? If so, how often?

How is your energy level from a level of 1-10?

How is your appetite?

How is your thirst? Are you thirsty often, or not very thirsty at all?

Do you experience any Headaches? Light headedness? Migraines?

Any congestions? Runny nose?

Any vision probems or changes in vision recently?

Any ear problems? Tinnitus? If tinnitus is it low or high pitched?

Any throat problems? Sore throat?

For women, please describe your menses (if applicable.) When was your last period? Please provide start and end date.

What color was the blood.

What was the flow: light or heavy?

Any clots?

Any cramping before, during, or after?

Does your period come at the same time every month and how many days does it last?

Please provide any other concerns that you would like to share that can be helpful.

Thanks You! I'll get back to you soon.