New Client Health History Intake Form
Please fill out this CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. Thank you.
If under 18, person responsible for your account:
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:
High Blood Pressure
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
For how long now?
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?
It comes and goes
Please indicate the symptoms or conditions you currently experience or have experienced them in the past:
Excessive Appetite: Currently
Loose stools / Diarrhea: Currently
Digestive problems: Currently
Gas or bloating: Currently
Worry thoughts: Currently
Lack of appetite: Currently
Low energy after a meal: Currently
Sweet cravings: Currently
Low blood pressure: Currently
Eye Problems: Currently
Difficulty Ingesting: Currently
Acid Reflux/ Heart burn: Currently
Easily Frustrated/ Angered: Currently
Difficulty making decisions: Currently
Ringing in the ears: Currently
Brittle hair or nails: Currently
High cholesterol: Currently
Heart Palpitations: Currently
Mentally Restless: Currently
Chest pain: Currently
Poor Memory: Currently
Sadness/ Loneliness: Currently
Agitation/ Fidgeting: Currently
Shortness of Breath: Currently
Decreased sense of smell: Currently
Tightness in chest: Currently
Grief/ Nostalgia: Currently
Lower back pain: Currently
Knee pain/ problems: Currently
Hearing impairment: Currently
High or low libido: Currently
Hair loss: Currently
Urinary problems: Currently
Blood & Dampness
Sluggishness/ Grogginess: Currently
Heavy feeling: Currently
Dark circles under eyes: Currently
Blood clotting disorder: Currently
I usually feel :
I’m often thirsty
Dry Mouth and Thirst
Age of first period:
Date of Last period:
Number of days between periods:
Number of days of flow:
Number of pregnancies:
Are you currently sexually active?
Please indicate color of blood and number of pads/tampons per day of flow below:
Pale/light red DAY 1-2
Bright red DAY 3-4
Dark red/brown DAY 1-2
Mild DAY 1-2
Moderate DAY 1-2
Severe DAY 1-2
Number of Pads
1-3 Pads DAY 1-2
4-7 Pads DAY 1-2
8+ Pads DAY 1-2
Please indicate if you experience the any of these symptoms during your menses:
Lower back pain
Scant or late menses
Date of your last prostate exam:
Are you currently sexually active?
Please list any STDs you have :
Please explain any concerns you may have with your sexual function or libido:
How many hours of sleep do you get each night?
Do you experience:
Difficulty falling asleep
Wake up not well-rested/groggy
How many bowel movements do you have in a day or week?
Are your bowel movements:
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:
If you have questions about the contents of this document, you can email the document owner.
Document Name: New Client Health History Intake Form
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