New Client Health History Intake Form


Please fill out this CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. Thank you.

Name:                                                                                   

Age:                              

Birth Date:  

Address:  

City:                                                                            

State:                                           

Zip:  

Phone number:   

E-mail address:                                                                                                                              

If under 18, person responsible for your account:   

Emergency Contact  

Name:                                                               

Contact Phone:   

Whom shall I thank for referring you to Nuurvana?   

Have you had acupuncture therapy before? 

 

Have you had a clairvoyant intuitive reading before? 

 

Please indicate if any of the following pertain to you:

Hepatitis  

HIV  

High Blood Pressure

Seizures  

Pacemaker  

Blood-Thinning Medication        

Pregnancy

 

Please indicate how frequently you consume the following:

Coffee How Often?

                                              

Soda How Often?

                                      

Water How Often?

 

Alcohol How Often?

                                      

Tobacco  How Often?

 

Please list any prescription or over-the-counter medications and supplements you are presently taking:

Medication / Supplement                           

Reason                                                     

For how long now?   

 

Health History

Please indicate your top 3 health concerns for which you are seeking treatment and how long you have been experiencing them:

 

What other forms of treatment have you sought?  

What helps your condition?  

What aggravates your condition?   

What would you like to achieve with our intuitive acupuncture sessions?    

 

As we will discuss, your health transformation is a process.

Please include your short-term health goals:  

Please include your long-term health goals:   

 

Please indicate your level of commitment to these goals.  (How frequently will you be coming in? Will you carry out suggestions, including dietary modifications, that you may be recommended?)

10: Really committed, 1: Not at all

 

 

Please list any surgeries or major health incidents (accidents, etc.) in your life and the date of occurrence:  

 

If you experience any physical pain, please indicate where and since when:   

 

How would you characterize your physical pain?

Dull/Achy

Sharp/stabbing

Burning

Tingling /numbness

Electrical

Continuous

It comes and goes

Fixed location

Moves around

Shooting/ radiating

 

Symptoms Survey

 Please indicate the symptoms or conditions you currently experience or have experienced them in the past:

 

Earth                                    

Excessive Appetite:  Currently

  Past

 

Loose stools / Diarrhea:  Currently

  Past

 

Digestive problems:   Currently

  Past

 

Gas or bloating: Currently

  Past

 

Obsession:  Currently

Past

 

Worry thoughts:  Currently

Past

              

Lack of appetite:  Currently

Past

               

Fatigue:  Currently

Past

                            

Low energy after a meal:  Currently

Past

   

Sweet cravings:  Currently

Past

                   

Hemorrhoids:  Currently

Past

                

Low blood pressure:  Currently

Past

         

 

Wood  

Eye Problems:  Currently

Past

 

Jaundice:  Currently

Past

 

Difficulty Ingesting:  Currently

Past

 

Belching:  Currently

Past

 

Acid Reflux/ Heart burn:  Currently

Past

 

Easily Frustrated/ Angered:  Currently

Past

 

Depression:   Currently

Past

 

Difficulty making decisions:  Currently

Past

 

Gallstones:  Currently

Past

 

Ringing in the ears:  Currently

Past

 

Brittle hair or nails:  Currently

Past

 

High cholesterol:  Currently

Past

 

 

Fire

Insomnia:  Currently

Past

 

Heart Palpitations:  Currently

Past

 

Nightmares:  Currently

Past

 

Mentally Restless:  Currently

Past

 

Chest pain:  Currently

Past

 

Poor Memory:  Currently

Past

 

Sadness/ Loneliness:  Currently

Past

 

Agitation/ Fidgeting:  Currently

Past

  

 

Metal

Cough:  Currently

Past

 

Shortness of Breath:  Currently

Past

 

Decreased sense of smell:  Currently

Past

 

Colitis/diverticulitis:  Currently

Past

 

Tightness in chest:  Currently

Past

 

Constipation:  Currently

Past

 

Grief/ Nostalgia:  Currently

Past

 

Claustrophobia:  Currently

Past

 

 

Water

Lower back pain:  Currently

Past

 

Knee pain/ problems:  Currently

Past

 

Hearing impairment:  Currently

Past

 

High or low libido:  Currently

Past

 

Hair loss:  Currently

Past

 

Urinary problems:  Currently

Past

 

 

Blood & Dampness

Arthritis:  Currently

Past

 

Sluggishness/ Grogginess:  Currently

Past

 

Nausea:  Currently

Past

 

Heavy feeling:  Currently

Past

 

Dark circles under eyes:  Currently

Past

 

Blood clotting disorder:  Currently

Past

 

 I usually feel :

Hot  

Cold  

I’m often thirsty  

Dry Mouth and Thirst

 

FOR WOMEN

 Age of first period:   

Date of Last period:   

Number of days between periods:  

Number of days of flow:   

Number of pregnancies:   

Miscarriages:   

Abortions:  

Are you currently sexually active?

 

Partners are: 

 

Please indicate color of blood and number of pads/tampons per day of flow below:

Color

Pale/light red  DAY 1-2

  DAY 3-4

  DAY 5+

 

Bright red DAY 3-4

DAY 3-4

DAY 5+

Dark red/brown DAY 1-2

  DAY 3-4

  DAY 5+

 

Cramping

Mild DAY 1-2

  DAY 3-4

  DAY 5+

 

Moderate  DAY 1-2

DAY 3-4

  DAY 5+

 

Severe  DAY 1-2

  DAY 3-4

  DAY 5+

 

Number of Pads

1-3 Pads  DAY 1-2

  DAY 3-4

  DAY 5+

 

4-7 Pads DAY 1-2

  DAY 3-4

  DAY 5+

 

8+ Pads DAY 1-2

  DAY 3-4

  DAY 5+

 

 

Please indicate if you experience the any of these symptoms during your menses:

Lower back pain            

Diarrhea  

Constipation    

Moodiness/Weepy        

Breast pain/soreness

Blood clots          

Increased appetite                  

Decreased appetite      

Headache

Nausea                

Insomnia                                    

More tired                                  

Hemorrhoids

Bloating              

Down-bearing sensation                    

Scant or late menses    

Irregular menses

 

For Men

Date of your last prostate exam:                       

Are you currently sexually active? 

 

Partners are: 

Please list any STDs you have :  

Please explain any concerns you may have with your sexual function or libido:  

 

Lifestyle

 

How many hours of sleep do you get each night?   

 

Do you experience:

Difficulty falling asleep        

Staying asleep  

Interrupted sleep                     

Nightmares        

Vivid dreams    

Wake up not well-rested/groggy

 

How many bowel movements do you have in a day or week? ­­­­­­­­

 

Are your bowel movements:

Well-formed           

Loose        

Small pebbles    

Tan            

Almost black

Easy to pass                      

Difficult to pass                                  

Sticky, like you have to wipe a lot

 

How would you rate your energy level on a scale of 1-10, with 10 being the highest: 

 

 

How would you rate your stress level on a scale of 1-10, with 10 being the highest: ­­­­­­­­­

 

Please list your primary sources of stress:   

 

How much do you think about them? How much do they impact your life?  

 

How many hours do you work per week? 

 

Do you like your work?

 

What do you do in order to manage your stress and take care of yourself?  

 

Did I miss anything? Anything else you’d like me to know?  

Leave this empty:

Signature Certificate
Document name: New Client Health History Intake Form
Unique Document ID: 6778d143e58f55262ff913e646f565e6122638da
Timestamp Audit
2015-04-13 20:00:18 UTCDocument New Client Health History Intake Form
Uploaded by Deganit - hello@nuurvana.com
IP: 68.175.118.144