Patient Intake Form

Personal Information

Emergency Contact Information

Doctor Information

Emotion / Memory

Emotion / Mood

Energy

Female Health

HT/SI (Fire)

KID/UB (Water)

LIV/GB (Wood)

LU/LI (Metal)

Oncology

Prenatal

SP/ST (Earth)

Conditions

Area of Complaint

Headaches

Blood

Cardiovascular

Endocrine

Gastrointestinal

Hearing

Immune

Kidney

Musculoskeletal

Neurological

Reproductive

Respiratory

Skin

Miscellaneous

Additional Information

Patient Summary