Acute Intake 1Complaints & Symptoms2Location3Aetiology4Modalities5Sensations NameYour Name First Last Patient's NamePatient's Date of Birth MM slash DD slash YYYY Email Phone1. Complaints (Symptoms)What is the main symptom or complaint that brought you here today?How did the symptoms start? Were they sudden or gradual?Can you describe your symptoms in detail? For example, are they sharp, dull, throbbing, burning, etc.? Are there any specific sensations you are feeling (e.g., pain, discomfort, pressure, heaviness)?Are your symptoms constant, or do they come and go?Have you noticed any patterns in your symptoms? Do they occur at specific times of day or night?Do you experience any other symptoms alongside the main complaint? (e.g., fever, nausea, chills, cough, fatigue)Do you experience any other symptoms alongside the main complaint? (e.g., fever, nausea, chills, cough, fatigue)Are there any unusual symptoms? 2. LocationWhere exactly are you feeling the symptoms? Can you point to the exact area or describe the region where it is located? Be sure to include the side of body or if it started on one specific side and moved to another.Does the pain or discomfort stay in one area, or does it move around your body? If there is pain, does it radiate to other areas (e.g., down the arm, across the chest)? 3. AetiologyIs there any particular event or stressor that preceded the onset of your illness?Is there any other cause you can think of? 4. ModalitiesKeep in mind movement, light, noise, lying, sitting, drinking etc.Are there any specific activities, movements, or actions that WORSEN the symptoms?Are there any specific activities, movements, or actions that IMPROVE the symptoms?Does the time of day affect your condition? For example, are the symptoms worse in the morning, afternoon, or night?Are there certain weather conditions or temperature extremes that aggravate your symptoms? Are you suddenly sensitive to cold or draft? Are you suddenly feeling very hot and need fresh air? Please detail carefully.Does being outside, in the sun, or in fresh air help improve or worsen your symptoms? Please specify worse / better when answeringAre there any foods or drinks that make you feel worse or better. Please specify worse / better when answering:Are you thirsty or thirstless?Are you thirsty or thirstless? thirsty thirstless Are you thirsty for freezing cold drinks or room temp?Are you drinking large amounts at a time or small sipsDoes any specific body position (sitting, standing, lying down) make it better or worse? Please specify worse / better when answering:Have you found anything that helps alleviate the symptoms? (e.g., heat, cold, rest)If you’ve been to a doctor or taken any over-the-counter medications, please list anything you’re currently taking.Are there any foods or drinks that you specifically crave or avoid during illness? Please specify crave / avoid when answering.Do you feel more sensitive to things than usual? (e.g., noise, light, touch, or smells)How have you been feeling emotionally during this illness? Are you feeling more anxious or irritable than usual? Desiring company or irritated by people around and want to be alone? 5. SensationsHow would you describe the pain or discomfort? Is it sharp, burning, stinging, cramping, or dull?If you have a cold, is the nose mucous green, yellow or clear? If clear, is it watery or stringy?If you have a cough, is it wet or dry? Are you coughing up mucous? If yes, describe the mucous. Describe all symptoms as best possible.Is there anything else you’d like to share?Remedy Notice I understand if you are able to prescribe a remedy I will not be able to take any motrin, advil or tylenol for the next few days as it will interfere with the remedy. I commit to not drinking any coffee for the next few days to ensure nothing cancels the remedy.
