Cat Calhoun, PhD, MSAOM, L Ac

9999 Dont I Wish I Could Live Here Blvd, Suite 9 San Francisco, CA 99999
Phone: (999) 999-9999 Fax: (999) 999-9999

New Patient Intake Form

This is totally confidential and is used only for me to determine the best plan of treatment for you. Please fill it out
as completely as you can by typing in the blanks and hitting the Tab key to advance through the fields. Thanks!

Personal Information
Name:
Emergency

Contact Name:
Have you had acupuncture before?
Yes
No

Age:
Todays Date:
Emergency

Contact Phone:
If yes, what were
you treated for?

How often and how much of the following do you consume?

Water:

Coffee

Alcohol:

Tobacco

Artificial
Sweeteners
:

Sugar:

Sodas:

Iced Tea
(black or green):

Please list any prescription or over-the-counter meds you take currently. Include herbs and supplements too.
Please attach a separate sheet if you need more room or just bring a list in with you for your appointment.
Medications/Herbs/Supplements
Reason

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Your Health History

What is the main health problem for
which you are seeking treatment?
How long have you had

this condition?
What other forms of treatment have
you tried?
What makes it better?

Are there any other problems youd

like to tackle?

1.

2.

3.

How did it start?

What makes it worse?

Please check any conditions youve had in the past. Well get to current stuff on another page.
Addiction (drugs, food,

COPD

High Cholesterol

Tonsillitis

Diabetes
Digestive Disorders
Eating disorders
Elevated liver
enzymes
Emotional Imbalance
Emphysema
Epilepsy
Fibromyalgia
Food, chemical or
drug poisoning
Gall stones
German measles
Glaucoma
Goiter
Gout
Heart disease
Hernia
Hepatitis

Hypertension
HIV positive
Malaria
Measles

Tuberculosis
Typhoid Fever
Ulcers
Venereal Disease

Mononucleosis
Multiple Sclerosis
Mumps
Nephritis
Neuralgia

Low blood pressure

Hysterectomy
Kidney problems
Depression
Mental disorders

Paralysis
Polio or meningitis
Prostate problems
Rheumatism
Scarlet fever
Small pox
Stroke
Thyroid problems

Suicidal thoughts

smoking)

AIDS
Alcoholism
Anemia
Appendicitis
Arteriosclerosis
Arthritis
Asthma
Bladder disease
Breast lumps
Breathing problems
Bulemia
Bursitis
Cancer
Candida
Chicken pox
Chronic fatigue
Colitis/bowel disease
Surgeries:

Significant Traumas (Accidents, disasters, death of loved ones):

Allergies:
What kind of regular exercise do you do?
Do you have any kind of occupational stress? If so, please describe:

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Your Family Medical History

Please check all that apply
Diabetes

Cancer

Breast Cancer

Asthma

Allergies

Heart Disease

Kidney
disorders

Alcoholism
or addictions
Stroke

High blood
pressure
Hysterectomy
Depression,
emotional
disorders

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Low blood
pressure
Prostate
problems
Suicide

Your Symptoms and Current Medical Status

Please place a checkmark next to any symptom or conditions you have now or experience frequently.
Loose stools or
diarrhea
Belching
Lack of appetite

Indigestion

Nausea or vomiting

Acid reflux

Varicose veins
Diabetes or hypoglycemia

Anemia
HIV positive
or AIDS
Eating disorder

Bruise easily
Sweat easily

Heart palpitations
Easily startled

Restlessness
Chest pain

Arthritis

Poor vision

Feeling of retenProlapsed organs

tion of food in
stomach
Tendency to become obsessive in work or relationships
Insomnia. Time?

Nightmares or
Anxiety attacks
sleep disturbed by
dreams
Racing of heart
Irregular heartbeat

Suicidal feelings

Headaches/migraines. Where are they usually and when do you get them?
High/low blood
pressure
Dizziness
Eczema
Difficult bowel
movements
Depression
Cough

Cataracts

Sinus congestion,
frequent infections
Weak voice
Nasal discharge:

Gallstones
Shoulder or neck tension
Hemorrhoids

Spots before eyes

(floaters)
Shingles
Sciatica
Hepatitis

Fullness behind the ribs

Bronchitis

Indecisiveness
Sadness

Asthma

Sore throat

Constipation
Clear

White

Yellow

Recent use of
antibiotics
Green
Bloody

Thick

Skin problems:
Hearing loss

Low back pain

Weak or sore knees

Hair loss
Osteoporosis

Prostate disorders
Teeth/gum problems

Spontaneous
sweating
Dislike of physical
movement
Blurred vision

No energy to speak

Impotence
Reduced sexual
energy
Lack of strength

Ringing in ears
Herpes
Impatience
Soft or brittle
nails
Easily angered
Shallow
breathing
Shortness of
breath
Emphysema
Thin/watery
Edema or
swelling
Urinary disorders
Fearfulness

General physical
weakness
Dry, brittle hair

General fatigue
Poor memory

Skin rashes

Cold hands and feet

Lack of thirst

Easily chilled
Desire for hot
drinks

Desire for cold

drinks

Numbness (where):
Aversion to cold
Frequent clear
urination

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Frequently thirsty
Low-grade
afternoon fever

Hot hands and feet

Dry throat

Night sweats
Red, flushed cheeks

Other:

Pain Patients
After you complete this form, print it out and shade or circle the areas where you feel pain.

How would you characterize your pain?

Dull or
Sharp or
Burning
achy
stabbing

Tingling

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Numbness

Electrical
shock

Gynecological Information
Any possibility you are pregnant?
Number of:
Pregnancies:

Yes

Births:

No

Birth control:

Miscarriages:

Abortions:

C-Sections:

PAP
Date of last PAP:
Vaginal sores?

Pap results:

Menstrual flow (skip it if youre in menopause and no longer bleeding):

Heavy
Light
Clots
Color of Menses:
Length of period:
Age of 1st period:

Painful

# Days between periods:

Date of last period:
Spotting between periods:

PMS
Breast soreness
Cramps
Perimenopause
Skipped or
irregular periods
Age at menopause:

Bloating
Other: ____
Hot flashes

Moodiness

Irritability

Moodiness

Vaginal dryness

Hysterectomy
age/reason:

Vaginal Discharge (describe):

Breast lumps
or cysts:
Other:

Endometriosis
(when):

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Final Bits
Favorite season:

Least favorite season:

How would you describe your overall emotional state?

Anything else youd like to discuss:

For Your Information

Please read following:
1. I only use sterile, disposable needles.
2. Occasionally acupuncture can leave a small hematoma (bruise under the skin). This is not a
cause for concern as it will go away in a few days. Gentle pressure applied at the site will stop
any small amount of bleeding that is occurring under the skin.
3. If I recommend herbs for you, I am recommending them for you and not for anyone else. Please
dont give your herbal prescriptions to anyone else!
4. After receiving acupuncture treatment you might feel a little lightheaded (and sometimes
euphoric). Please feel free to have a seat, drink a little water and relax to let yourself come back
to normal. In a few minutes you will feel relaxed and clear headed.
5. You may be asked to see a physician or chiropractor for your condition if needed. Please do so if
it is within your means. I will only ask this of you when I believe it to be necessary.
6. All fees are payable prior to your treatment.

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Informed Consent to Treatment

I, the undersigned, hereby request and consent to treatment by acupuncture and/or other procedures within the
scope of the practice of acupuncture. Methods of treatment may include, but are not limited to, acupuncture,
moxibustion, cupping, electrical stimulation, guasha, herbal therapy, bodywork, Reiki and medical Qigong.
I am hereby informed that the aforementioned treatment methods are all generally safe but that there may be some
side effects or risks, as follows:
Acupuncture may potentially cause temporary bruising, swelling, bleeding, numbness and tingling, or
soreness at the site of needling. Unlikely risks of acupuncture include lung puncture (pneumothorax), nerve
damage, organ puncture, and infection - although I use only sterile, disposable needles and maintains a clean
and safe environment.
Potential risks of moxibustion include blistering, burns, and scarring. Common side effect of cupping and gua
sha are temporary bruising and redness lasting a few days.
The herbal and nutritional supplements (which may be from plant, animal, or mineral sources) recommended
to me are generally safe in the traditionally recommended doses. Possible side effects of herbs include nausea,
gas, stomache ache, diarrhea, and headache. Unusual side effects of herbs include vomiting, rashes, hives, and
tingling of the tongue. I understand I must stop taking any herbs and notify my acupuncturist if I experience
any discomfort or adverse reaction.
I will notify the acupuncturist should I become pregnant or if I am in the process of trying to get pregnant as
certain acupuncture points and herbs are contraindicated during pregnancy and could induce miscarriage.
I understand that I can discuss risks and benefits further before signing if I so choose, although I do not expect
my practitioner to be able to anticipate and explain all possible risks and complications of treatment. I rely on
my practitioner to exercise her judgment in my best interest during the course of treatment, based upon the
facts then known.
I fully understand that there is no implied or stated guarantee of success or effectiveness of a specific
treatment or series of treatments.
I understand that my practitioner will keep all of my records confidential.
In signing this form, I acknowledge any inherent risks, and give my consent for treatment; healthcare operations
received, incurred or carried out by my practitioner.
__________________________________________________________________________________________
Signature of Person being treated
Date

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