Points for Peace Confidential Intake Form

Name______________________________ Date________________Email_________________________________

1
Why are you here today? How are you feeling compared to the last time you were here?
How does your
body feel ?
Draw it!
Notes!
Points for Peace Confidential Intake Form
Energy & Emotions
I have been having trouble with:
(Circle all that apply)

Anger
Irritability
Sensitivity
Outbursts
Worry
Racing or-Repeating Thoughts
Poor Memory
Hyperactivity
Anxiety
Difculty Concentrating
Fatigue
Sadness
Depression
Grief
Boredom
Isolation

Sleep
I sleep____hours per night.
I have difculty w/: Vivid Dreams
Falling sleep / Staying asleep/Getting up


What do you do to Relax & Have Fun?



What Practice, Image or Story calms & centers you?



Hows your Energy?
Too little/Enough/Too Much/ Uneven




What is your Primary Concern today - the main
thing that you want to work on improving?
2
Points for Peace Confidential Intake Form
Please circle all of the following
symptoms that apply:
This / That

Headaches
What are they like?

Recent / Recurrent & Chronic
Sharp / Dull / Throbbing/
Dizziness

When are they?

Morning / Noon / Evening

Where?

Back of Head/ Neck
Forehead/ Temples
Sides of head/ Top of head
Whole head/ Behind Eyes

Aches, Pains or Numbness
Where is the primary area?
Type: Ache/Pain / Numbness
Whole Body
Chest / Abdomen / Ribs/ Hips
Shoulders /Hands/Arms/Elbows/
Hips/Knees/Feet
Back: Upper/ Mid/ Lower

Whats the pain like?

Sharp / Stabbing / Dull
Throbbing/ Cramping
Heavy / Swollen/ Radiating
Feel to touch: Hot / Cold/ Numb

Rate Discomfort 1-10:_______

What makes the pain better?
Pressure / Heat / Cold
Rest / Activity / Eating

Digestion, Food & Tastes
My relationship with food:

No appetite / Excessive Appetite
Bingeing/ Cravings for - Sugar?
Salt?/ Other:_________________

I have trouble with:

Indigestion /Belching / Bloating /
Gurgling
Nausea / Vomiting / Ulcers
Acid regurgitation / Heartburn
Hernia / Severe Stomach Pain

After Eating I feel:
My Best / Bad / Tired
Pain

Taste in Mouth:
Bitter/ Sweet / Sour / Salty /
Pungent / Spicy
3
Points for Peace Confidential Intake Form
I like Drinking:
Hot drinks / Cold drinks/ with ice
# ____Caffeinated drinks/day
#____ Alcoholic drinks/week
Problem for you? Caffeine/Alcohol

Bowels & Urination
Generally: Constipation / Diarrhea
Alternating / Pain with Pooping

My poop looks:

Formed / Loose /Pebble/Bloody
with: Undigested food /Mucus

Daily Bowel Movements (BM):
1-2 BM per day/ More/ Fewer

Urination:
Frequent/ Leakage/ Pain
I wake to pee_____times/night

Frequent Infections
What kind?____________________
Throat or Chest/ Ears/ Sinus/UTI

Eyes, Ears & Nose
I experience:
Ringing in ears/ Floaters in eyes /
Shortness of Breath
Allergies: Itchy eyes, ears, nose
Sinusitis / Stuffy or drippy nose /
clogged or constricted throat

Skin&Hair
I have difculty with:
Eczema / Psoriasis / Acne
Itching / Rashes / Hives/ Dryness
Hair:
Premature greying / Hair Loss
Women
Last Period:___________________
# of Days ow__________
Women cont.
The blood is: Bright/Dark/Pale
with: Clots / Cramping / Bloating

Before period:
Sensitivity/ Breast Tenderness
Discharge
Yeast infections

Men
Trouble with Erections
Pain in Testicles / Hernia
Inamed Prostate
Anything else:___________________

Sexuality
Im having a difcult time with:
Physical Function/ Desire/ Pain
Energy/ Partner(s) /Attitude



4
Points for Peace Confidential Intake Form
Past Medical History
Please describe any signicant injuries, surgeries, major
illnesses whether you were hospitalized or not?








Women
Are you presently pregnant or trying to get pregnant?
Pregnant/ Trying / Neither
Past Pregnancies_______
Miscarriages ________
Abortions________

Supplements/ Medications/Herbs
Include what you are using them for:




Recreational Drug use
Marijuana: Daily/ Weekly/ Problem for you? Little/ Big
Coke: Daily/Weekly/ Problem for you? Little/Big
Other:______________________Daily/Weekly/Monthly

Have you had any of these conditions? When?
PLEASE ADD DATE (EST. OK)
Frequent Childhood Illnesses
HIV/ AIDS
Alcoholism
Drug Addiction
Asthma
Birth Trauma (your own)
Cancer
Diabetes
Emphysema
Heart Disease
Hepatitis A/ B /C
Herpes
Lyme Disease
Multiple Sclerosis
Pacemaker
Polio
Rheumatic Fever
Scarlet Fever
Seizures
Tuberculosis
Latex Allergy
Lymph Nodes Removed
Tonsils Removed
Hysterectomy
Anything else removed:______________________
Other:_____________________________________
5
Points for Peace Confidential Intake Form
ATTUNMENT NOTES
NAME:__________________________________ DATE:________________
6
Points for Peace Confidential Intake Form

TONGUE Pulse

HT/SI LU/LI

LV/GB SP/ST

KD/UB PC/TH

Circuit & Elements
Pattern of Fatigue
LU LI ST SP` Spinal Irritation
HT SI UB KD Diaphragm Constriction
PC TH GB LV Cardiac Alarm
Pelvic Collapse

Fire
Next Steps:
Wood Earth Treatment Principle

Metal

Water
Points Muscles
7

Palpation