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__________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
