TAMARA WOLFSON, MS, LAc
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Medical Intake Form
Tamara Wolfson, MS, LAc, NCCA
85 Bolinas Road, Fairfax, California  
California License #9117
415-378-1666
tamara@tamarawolfson.com

Date____________________

Name_______________________________________

Address________________________________________________________________
______________________________________________________________________
Phone_______________________________________

Email________________________________________
Where did you hear about me?_________________________________

Chief Complaint 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Date of Onset___________________________________________________________________________

To be in balance with nature is to be successful. Earl Spenser, Farmer 

3 Month Health Goals_________________________________________________________________________________

1 Year Health Goals_________________________________________________________________________________

5 Year Health Goals_________________________________________________________________________________

Each individual actualizes his/her full human potential only as a result of physical, emotional, intellectual, spiritual well-being and that those four aspects of existence are always contingent on external things.

What is your vision?_________________________________________________________________________________
_________________________________________________________________________________
 _________________________________________________________________________________

What is your tradition/place in the world? What are its songs?
_________________________________________________________________________________
 _________________________________________________________________________________

Describe your relationship with:

household _________________________________________________________________________________

neighborhood _________________________________________________________________________________

community _________________________________________________________________________________

40 acres_________________________________________________________________________________

1000acres_________________________________________________________________________________

 

What are your key relationships?
_________________________________________________________________________________
 _________________________________________________________________________________

How would you describe your relationship with: 

Self_________________________________________________________________________________

Family/Ancestors_________________________________________________________________________________

Community_________________________________________________________________________________

Land_________________________________________________________________________________

 

What actions need to be taken?

Short term_________________________________________________________________________________

Long term_________________________________________________________________________________

 

 

Medical history, any accidents surgeries, disease diagnosis?______________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are your parents alive and have they been diagnosed with any medical conditions?____________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever experienced acupuncture before, when, with whom?________________________________

Has this condition been previously treated and or diagnosed, if so, by whom?________________________

Have you eaten today?_________________________

Blood pressure?_______________________________

Are you pregnant?___________________________________

Any significant weight changes?________________________

Are you taking any medications, herbs or supplements?_________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have any skin sensitivities?______________________

Do you have pain in your body? Where? How severe on a scale from one to ten (ten being most severe)?, When did it begin? What is the quality of the pain; sharp, dull, moving, worse with heat or cold?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What helps the condition?_________________________________________________________________

Postural Concerns and/or Repetitive Strain Injury?_____________________________________________
____________________________________________________________________________________________________________________________________________________________________________

Any chills and/or fever?___________________________________

Any sweating, day or night?________________________________

Qualities of appetite and thirst?______________________________

Eating habits?____________________________________________

Any bloating, gas, indigestion, acid reflux?__________________________________________________

Sleep and Dreams:

Please describe, quality and frequency.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Diet:

Be  specific. Include all foods eaten, breakfast, lunch, dinner.

Do you eat with family?

Do you eat regularly?

Do you cook?
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Quality of stool; frequency, diarrhea or constipation?___________________________________________

Urination, frequency, color, nighttime?______________________________________________________

Sleep habits and quality?__________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you experience fatigue?_______________________________________________________________

Libido strength and sexual issues?__________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________

Menses

Cycle regularity, how many days?____________________________________________

Amount?________________________________________________________________

Color?__________________________________________________________________

Clots?__________________________________________________________________

Pain?___________________________________________________________________

Breast tenderness?_________________________________________________________

Emotional changes?________________________________________________________

PMS?___________________________________________________________________

Vaginal discharge, color, odor?_______________________________________________

How many pregnancies?____________________________________________________

How many children?_______________________________________________________

 Do you tend to feel hot or cold?_______________________________________________

Are your hand and feet hot or cold?____________________________________________

Exercise routine?___________________________________________________________

Relaxation practices?________________________________________________________

Remarks_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Pulse______________________________________________

Tongue_____________________________________________

Palpation, Discoloration__________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________

Diagnosis______________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Treatment Plan ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Homework, Suggestions for Client__________________________________________________________
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visit my sister websites at www.TheBeeHealer.com and www.LadyBeeBotanicals.com
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