Acute Intake 1Complaints & Symptoms2Location3Cause / Trigger4Modalities5Sensations 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)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?Complaint #1Complaint #1 - Location Left sided Right sided Started on left, moved to right Started on right, moved to left Started left, then right then left Started right, then left, then right Constantly alternating sides Not specific to one side Complaint #2Complaint #2 - Location Left sided Right sided Started on left, moved to right Started on right, moved to left Started left, then right then left Started right, then left, then right Constantly alternating sides Not specific to one side 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)?Be as specific as possible. 3. Cause / TriggerIs 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?Is there a window of time when your symptoms WORSEN?Is there a time of day when your symptoms IMPROVE?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.Are you hotter or colder than usual, please check all that apply if it’s different than your usual state: Feeling much colder than usual / bothered by a cold room Feeling much warmer than usual / bothered by a warm room Need to be covered at all times Do not want to be covered Cannot get warm Need fresh air / open air. Hotter / Colder descriptionDoes being outside, in the sun, or in fresh air affect your symptoms?Please check all that apply Being outside in the sun IMPROVES symptoms Being outside in the sun WORSENS symptoms Being outside in the fresh air IMPROVES symptoms Being outside in the fresh air WORSENS symptoms Are there any foods or drinks that make you feel WORSE?Are there any foods or drinks that make you feel BETTER?Please describe thirst if it’s different than their usual thirst.Check all that apply, please choose very accurately: Very thirsty for small sips often Very thirsty for large amounts at a time. Thirsty for freezing cold drinks. Desire warm drinks Thirstless What drinks are you craving?Is there a specific body position (sitting, standing, lying down) that IMPROVES your symptoms?Is there a specific body position (sitting, standing, lying down) that WORSENS your symptoms?Have you found anything that helps alleviate the symptoms? (e.g., heat, cold, rest, motion/movement, drinking, eating, etc.)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 during illness?Are there any foods or drinks that you specifically AVOID during illness?Do you feel more sensitive to things than usual?How have you been feeling emotionally during this illness? Are you feeling more anxious or irritable than usual?Be as specific asHave you been preferring to be alone or to be with company?Please describe appearance of tongue - check all that apply: Coated yellow Coated white Thick coating Indentations / scalloped tongue Spots on tongue Tongue Comments 5. SensationsHow would you describe the pain or discomfort? I.e., is it sharp, burning, stinging, stitching (needles), cramping, throbbing, pressing, sensation of a band, dull etc.?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.
