This is what I use as a guide during the intake interview with my clients. It is only a guide and I will most likely add questions and leave parts out. This is not a form for you to fill out.
Name______________________Age_____height_____weight______________Date_________ Occupation____________________________________________________________________Married_____________children___________________________________________________
Complaints:Emotional/physical __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
1-10 scale______________________________________________
Frequency/how often:____________________________________________________________
______________________________________________________________________________
Onset: When(date), changes/timing/history:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
How did you feel?_______________________________________________________________
____________________________________________________________________________________________________________________________________________________________
What makes better/worse (food, herb/drug, activities, emotions):__________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Best times of the day/season/weather________________________________________________
____________________________________________________________________________________________________________________________________________________________
Lab tests/diagnosis, info from doctors or other practitioners (past/present):__________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medications (antibiotics, stomach acid blockers), alternative treatments, self medication (dose and purpose): __________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Affect other parts of life/body (mental/physical)?______________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
1-10 sclae_____________________________________________________________________
Does pain move and/or alternate?___________________________________________________
____________________________________________________________________________________________________________________________________________________________
Bowel movements_______________________________________________________________
______________________________________________________________________________
Sleep patterns__________________________________________________________________
_____________________________________________________________________________
Night sweats(false heat), night conditions(yin)?_______________________________________
enegy level (1-10)_______________________________________________________________
skin dry/moist__________________________________________________________________
hobbies_____________________________________________________________________________________________________________________________________________________
breakfast________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
lunch___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
dinner________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
exercise_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
snacks____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Cravings____________________________________________________________________________________________________________________________________________________
desert/candy_______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Coffee/tea, beer, tobacco, drugs?___________________________________________________ ____________________________________________________________________________________________________________________________________________________________
hot/cold ______________________________________________________________________
heavy/light menstruation?__________________________Menopause?_____________________
Family history: diseases, addictions, tragedy.__________________________________________ ____________________________________________________________________________________________________________________________________________________________
Changes in life/social evolution____________________________________________________
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
how do you feel in general throughout life?___________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
personality_____________________________________________________________________ ______________________________________________________________________________
Other health concerns/date of onset_________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
1-10 scale_____________________________________________________________________
tongue diagnosis ______________________________________________________________________________________________________________________________________________________
Goals with treatment_____________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
1-10?_________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________
Dosha________________________________________________________________________
______________________________________________________________________________
Tongue/face________________________________________________________________________________________________________________________________________________________________________________________________________________________________
E-mail_______________________________Phone___________________________
At your follow-up visit, what were the results of your treatment? How did your patient comply with the treatment?