Free Range Acupuncture
Confidential Intake Form
Name______________________________ Date________________Email_________________________________ How does your body feel ? Draw it!
Notes!
 
Why are you here today? How are you feeling compared to the last time you were here?
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Recommendations:! 1
Free Range Acupuncture Energy & Emotions I have been having trouble with: (Circle all that apply)
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Anger Irritability Sensitivity Outbursts Worry Racing or-Repeating Thoughts Poor Memory Hyperactivity Anxiety Difficulty Concentrating Fatigue Sadness Depression Grief Boredom Isolation
Confidential Intake Form
! • What do you do to Relax & Have Fun? ! ! ! • What Practice, Image or Story calms & centers you? ! ! ! • How’s your Energy? Too little/Enough/Too Much/ Uneven
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• What is your Primary Concern today - the main thing that you want to work on improving?
Sleep I sleep____hours per night. I have difficulty w/: Vivid Dreams Falling sleep / Staying asleep/Getting up
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Recommendations:! 2
Free Range Acupuncture
Confidential Intake Form
Please circle all of the following
Aches, Pains or Numbness
Digestion, Food & Tastes
symptoms that apply:
Where is the primary area?
My relationship with food:
This / That
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Headaches What are they like?
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Recent / Recurrent & Chronic Sharp / Dull / Throbbing/
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Dizziness
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Morning / Noon / Evening
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Back of Head/ Neck Forehead/ Temples Sides of head/ Top of head
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Whole Body
No appetite / Excessive Appetite
Chest / Abdomen / Ribs/ Hips
Bingeing/ Cravings for - Sugar?
Shoulders /Hands/Arms/Elbows/
Salt?/ Other:_________________
Hips/Knees/Feet
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Back: Upper/ Mid/ Lower
I have trouble with:
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Indigestion /Belching / Bloating /
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Where?
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What’s the pain like?
When are they?
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Type: Ache/Pain / Numbness
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Sharp / Stabbing / Dull
Nausea / Vomiting / Ulcers
Throbbing/ Cramping
Acid regurgitation / Heartburn
Heavy / Swollen/ Radiating
Hernia / Severe Stomach Pain
Feel to touch: Hot / Cold/ Numb
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What makes the pain better? Pressure / Heat / Cold
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After Eating I feel:
Rate Discomfort 1-10:_______
Whole head/ Behind Eyes
Gurgling
Rest / Activity / Eating
My Best / Bad / Tired Pain
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Taste in Mouth: Bitter/ Sweet / Sour / Salty / Pungent / Spicy
Recommendations:! 3
Free Range Acupuncture I like Drinking: Hot drinks / Cold drinks/ with ice
Confidential Intake Form Frequent Infections
Women cont.
What kind?____________________
The blood is: Bright/Dark/Pale
# ____Caffeinated drinks/day #____ Alcoholic drinks/week Problem for you? Caffeine/Alcohol
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Bowels & Urination Generally: Constipation / Diarrhea Alternating / Pain with Pooping
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Eyes, Ears & Nose I experience: Ringing in ears/ Floaters in eyes / Shortness of Breath Allergies: Itchy eyes, ears, nose Sinusitis / Stuffy or drippy nose /
My poop looks:
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Formed / Loose /Pebble/Bloody
Throat or Chest/ Ears/ Sinus/UTI
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clogged or constricted throat
with: Undigested food /Mucus
Skin&Hair
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I have difficulty with:
Daily Bowel Movements (BM):
Eczema / Psoriasis / Acne
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1-2 BM per day/ More/ Fewer
Hair:
Urination:
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Itching / Rashes / Hives/ Dryness Premature greying / Hair Loss
Frequent/ Leakage/ Pain
Women
I wake to pee_____times/night
Last Period:___________________ # of Days flow__________
with: Clots / Cramping / Bloating
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Before period: Sensitivity/ Breast Tenderness Discharge Yeast infections
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Men Trouble with Erections Pain in Testicles / Hernia Inflamed Prostate Anything else:___________________
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Sexuality I’m having a difficult time with: Physical Function/ Desire/ Pain Energy/ Partner(s) /Attitude
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Recommendations:! 4
Free Range Acupuncture Past Medical History
Please describe any significant injuries, surgeries, major illnesses whether you were hospitalized or not?
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Women
Are you presently pregnant or trying to get pregnant? Pregnant/ Trying / Neither Past Pregnancies_______ Miscarriages ________ Abortions________
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Supplements/ Medications/Herbs Include what you are using them for:
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Recreational Drug use
Marijuana: Daily/ Weekly/ Problem for you? Little/ Big Coke: Daily/Weekly/ Problem for you? Little/Big Other:______________________Daily/Weekly/Monthly
Confidential Intake Form
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Have you had any of these conditions? When?
PLEASE ADD DATE (EST. OK) •Frequent Childhood Illnesses •HIV/ AIDS •Alcoholism •Drug Addiction •Asthma •Birth Trauma (your own) •Cancer •Diabetes •Emphysema •Heart Disease •Hepatitis A/ B /C •Herpes •Lyme Disease •Multiple Sclerosis •Pacemaker •Polio •Rheumatic Fever •Scarlet Fever •Seizures •Tuberculosis •Latex Allergy •Lymph Nodes Removed •Tonsils Removed •Hysterectomy •Anything else removed:______________________ Other:_____________________________________
Recommendations:! 5
Free Range Acupuncture
Confidential Intake Form
ATTUNMENT NOTES NAME:__________________________________ DATE:________________ 
Recommendations:! 6
Free Range Acupuncture
Confidential Intake Form
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Points
Palpation
Muscles
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Circuit & Elements Pattern of Fatigue
LU LI ST SP` HT SI UB KD PC TH GB LV
TONGUE
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Spinal Irritation Diaphragm Constriction Cardiac Alarm Pelvic Collapse
Pulse HT/SI
LU/LI
LV/GB
SP/ST
KD/UB
PC/TH
Fire Wood
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Earth
Next Steps:
Treatment Principle
Metal Water
Recommendations:! 7