CLIENT INTAKE Please Write Legibly
Name ____________________________________________________________
Date_________________
List any present complaints:
1. Feel cold often? _______ Dislike the cold? _______
Feel hot often? _______ Dislike the heat? _______
Have afternoon flushes/fevers? _______ Night or daytime sweats? _______
Hot palms or soles? ____________
2. Digestion: Tend to Constipation? Loose Stools? Bloating? Gas? Other
digestive issues?
3. Energy—Have enough? Appetite good?
_________
4. Have a big thirst? ___________________ Small but frequent thirst?
_______________________
Little or no thirst? ______________________________ Enjoy ice water?
________________________
5. Do you sleep soundly? _______ Fall asleep easily? _______
Wake up during the night? _______ If yes, how many times per night?
_______
Have lots of dreams?
6. Emotions. Excess? ________ Depression?_________ Unresolved
resentments?______________
Other issues:
7. Describe any pain, stiffness or swelling in your body:
8. Have headaches or dizziness?
9. Mucus/phlegm issues?
10. Sexual & Reproductive Health
Menses: Regular? _______ Painful? _______ PMS? _______
11. Is your urine clear like water? _______
turbid or cloudy _______ scanty _______ yellow _______ dark yellow _______
12. Favorite colors, seasons, and flavors [Circle: bitter, sweet, salty,
pungent or hot, sour]:
13. Aversions to colors, seasons, and flavors [Circle: bitter, sweet, salty,
pungent or hot, sour]:
14. Favorite time of day: __________ Low point during the day: ___________
15. Predominant emotions you experience [Circle: joy (excessive?),
worry/pensiveness, grief/sadness, fear, anger/frustration], list:
Continued on back:Please circle any conditions you tend toward or are
currently experiencing:
forgetfulness overweight asthma dry mouth allergies/ hay fever
intense dreams underweight bronchitis hearing loss highly
emotional
insomnia indigestion immune weakness ringing in ears bloating
restless sleep intestinal gas frequent colds/flus low back pain eye/visual
problems
speech problems diarrhea frequent cough dizziness morning
stiffness
confusion constipation skin eruptions teeth problems stiff neck
palpitations weak muscles rash/fungus low sex drive muscular pain
chest pains prolapses dry skin knee problems anger/ impatience
memory loss appetite disorder grief/sadness aversion to cold
swellings
heart trouble sugar craving irritable colon urinate often dry/red eyes
poor circulation hemorrhoids shortness of fear/insecurity high
blood press.
lack of spirit fatigue breath ear infections
vertigo
joyless worry perfectionist drug addiction mood swings
spaciness water retention congestion arthritis headaches
lack of focus ulcers excess mucus bone problems depression
addictions mouth sores fatigue/lethargy
stress/tension
often too warm cancer/tumors frequent thirst often too cold cramps/spasms
yellow mucus cysts/warts night sweats clear mucus paralysis/tremor
dry stool yeast infection hot palm/feet loose stools moving
pains
dark urine dislike dampness Tidal fevers clear urine
dislike wind
Please add your own comments about your health and what you would like this
session to accomplish for you: