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Tropical Beach

Begin Your Healing

Acupuncture Initial Intake

First Name

Last Name

Email

What are your health concerns and goals?

Allergies:

Vitamins/Supplements and reason for taking:

Medications and reason for taking:

Hospitalizations:

Do you have a pacemaker? * Required

Yes

No

Temperature:

Cold Hands and/or Feet

Sweaty Hands and/or Feet

Afternoon Flush/Fever

Night Sweats

Hot Flashes

Preference for Warm Drinks

Preference for Cold Drinks

Sweat Easily

Respiratory:

Shortness of Breath

Easily Catch Colds

Worse after Exercise

Nasal Discharge

Cough

Eyes:

Dry

Watery

Painful

Floaters/Spots

Visual Problems

Digestion:

Burning Sensation after Eating

Sores inside mouth (Cold Sores)

Bleeding, Swollen or Painful Gums

Ulcer (Diagnosed by Physician)

Stomach Pain

Digestion pt.2:

Low Appetite

Sudden Weight Change

Gas/Bloating

Fatigue after Eating

Easily Bruised

Brain Fog

Body:

Bitter Taste in Mouth

Irritability

Skin rashes

Numbness/Tingling

Muscle Tension/cramps

Dizziness

High Pitched Ringing in Ears

Low energy

Headache

Stool:

Constipation

Incomplete Evacuation

Loose Stools

Diarrhea

Blood in Stool

Mucus in Stool

Undigested Food in Stool

Urination:

Discolored

Scanty

Profuse

Strong Odor

Painful

Urgent

Heart and Sleep

Anxiety

Mental confusion

Palpitations

Frequent Dreams

Difficulty Falling Asleep

Difficulty Staying Asleep

Female - Gynecolegy:

PMS

Menopause

Irregular Periods

Abnormal Pap Smear

Infections

Other

Bones:

Frequent Cavities

Eaily Broken Bones

Low Back Pain

Memory Problems

Wake Frequently to Urinate

Low Pitched Ringing in Ears

Male - Genital:

Impotence

Nocturnal Emission

Pain/Itching/Lumps

Other

Number of Live Births

Number of Miscarriages

Number of Abortions

I have answered truthfully and to the best of my knowledge

Thanks for submitting!
Onto the last form!

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