Confidential new patient intake form



Word of mouth
Google
Facebook
Instagram
Doctor
True local
Internet voucher
Other

Amenorrhea
Anemia
Anxiety
Asthma
Back pain
Bladder problems
Bleeding disorder
Breast implants
Bronchitis
Cancer
Celiac disease
Chest pain
Constipation
Depression
Diabetes
Diarrhea
Digestive problems
Dizziness/Vertigo
Eating disorder
Epilepsy
Eye problem
Food/plant allergy
Gallbladder problem
Haemorroids
Hayfever
Headaches
Hearing problem
Heart problem
High blood sugar
High cholesterol
High blood pressure
Hepatitis
HIV/AIDS
Hyperthyroid
Hypothyroid
Infertility
Irregular periods
Joint replacement
Low blood pressure
Metal/silicon allergy
Migraines
Neck pain
Organ transplant
PCOS
PMT
Sinus problems
Skin problems
Sports injuries
Weight gain
Weight loss
Insomnia
Arthritis
None of the above

Low
Medium
High


Head or Face
Neck
Chest
Arms or Hands
Legs or Feet

Dull ache
Strong ache
Sharp stabbing
Searing
Diffuse
Specific

With movement
Without movement
All the time
With heat
With cold
With damp
Day
Night

Neck
Shoulders
Upper Back
Middle Back
Lower Back
Hips
Legs
Arms

Cannot sleep
Sleep too much
Can't fall asleep
Can't stay asleep
Wake to urinate
Wake from pain
Night sweats
Vivid dreams

Always low
Fluctuate
Tires easily
Better with exercise
Lots of energy
Wakes tired
Tired after eating
Tired in afternoon

Feels hot
Feels cold
Likes the heat
Prefers cold
Cold hands and feet
Hot feet
Likes hot drinks
Likes cold drinks

Daily
Weekly
Monthly
Front
Back
Sides
All over
Specific trigger

Not hungry can't eat
No appetite eat anyway
Average appetite
Binge eating
Emotional eating

Sour
Salty
Bitter
Sweet

Strong thirst
Weak thirst
Drinks heaps
Drinks Little
1L per day
More than 1L per day
Coffee or Tea
Sweetened Drinks

Copious
Frequent
Scanty
Pain
Dark colour
Night time
Urgency

Once daily
More than once daily
Every 2 to 3 days
Severe constipation
Pain
Loose stool
Watery diarrhea
Dry hard stool
Urgency

Bloating
Pain
Reflux
Nausea
Vomiting
Ulcer
IBS
Intestinal problem

Rib pain
Heart pain
Palpitations
Tight
Short of breath
Heavy
Anxiety
Cough

In throat
Blocked nose
Sinus congestion
Post nasal drip
Yellow or green
Clear or white

Dry
Oily
Rashes
Eczema
Red
Flaky
Acne
Puffy

Easily with exercise
Easily without exercise
At night
With hot flushes
With chills
A lot
A little
None

Often tender
Hurts in middle
Hurts on sides
Swollen glands
Dry
Stuck feeling

Partially deaf
Fully deaf
Hard of hearing
Tinnitus
Pain
Frequent Infections

Poor vision
Red
Dry
Puffy
Itchy
Tired
Painful

Upon rising in AM
Upon standing
With exercise
With movement
No pattern


Yes
No

Yes
No

Yes
No

Yes
No

Yes
No
Sometimes

Yes
No
Sometimes

Lower abdomen
All over abdomen
Lower back
Inner thighs
Back of legs
Top of legs
Urinary tract
Rectum
Prostate
None of the above

Yes
No

Yes
No

Yes
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