Marguerite Shinouda, L
Marguerite Shinouda, L.Ac.
NYS License #867
8 Nepale Drive 437 New Paltz Road New Paltz, NY 12561 Highland, NY 12528 T: (845) 532-4005 F: (845) 255-8046
Today's Date:_________
Name: _____________________ Date of Birth:__________________
Address: ___________________ Home Phone: __________________
_______________________________ Daytime/Mobil Phone:___________
Emergency Contact: _________ Email Address: _________________
Insurance Info(if Applicable): Member #________________Claim #_________________
Member name and birthday if different from patient:________________________________________
Date of Accident:____________ Insurance Company’s phone number:_________________________
Referring Doctor’s name and phone #:____________________________________________________
How did you hear about our practice?____________________________
Main Concern: Secondary Concerns:
______________________________ ____________________________________
______________________________ ____________________________________
What Makes it Better? What Makes it Worse?
(rest/stretching, hot/cold, seasons morning/evening, foods?)
_______________________________ ____________________________________
Other Current Treatments: Medications:
_______________________________ ____________________________________
_______________________________ ____________________________________
Allergies: Supplements:
________________________________ ____________________________________
_______________________________ ____________________________________
1 Medical History
Major Accidents and Month/Year of Occurrence: _____________________
______________________________________________________________________
Surgeries and Month/Year of Occurrence: __________________________
______________________________________________________________________
Major Illnesses and Month/Year of Occurrence: ______________________
______________________________________________________________________
Family Tendencies (diabetes, heart disease, cancer, high blood pressure):
______________________________________________________________________
Frequent Exposures (cold & damp, chemicals, x-rays, etc): ___________________
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Habits and Cravings (smoking, alcohol, sweets, etc)__________________________
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Frequency and Type of Exercise:_______________________________________
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Patient Intake Form
Please check all symptoms you have experienced within the last six months. If they do not apply, leave them blank. If you experience them frequently, check them twice. Some symptoms may be listed more than once, check them each time they occur.
Section 1: Bi Section3: Xue Section 5: Yin
My condition feels better… ___Pale face & nails ___Feverish in the afternoon
___with cold ___Blurry vision ___Night sweats
___with heat ___Palpitations ___Dry mouth
___with rest ___Numbness ___Dry throat
___with exercise ___Scanty menses ___Feverish palms & soles
___without pressure ___Short menstrual cycles ___Irritable
___with pressure ___Dizzy, lightheaded ___Insomnia
___in the morning ___Flushed cheeks
___through the day ___Localized sharp pain
___Lump, mass, or cyst Section 6: Jing
Section 2: Qi ___Painful menses ___Premature greying
___Easily fatigued ___Irregular menses ___Hair loss
___Shortness of breath ___Dark red spots ___Tooth loss
___Spontaneous sweating ___Infertility
___Dizziness(Lightheaded) ___Feverish ___Impotence
___Hard to project voice ___Irritable ___No sex drive
___Bleeding ___Memory loss
___Intermittent dull pain ___Red, painful skin eruptions
___Bloating/Fullness ___Heavy menses Section 7: JinYe
___Sighing ___Hoarse voice
___Stuck feeling in throat Section 4: Yang ___Dry mouth
___Repeated throat clearing ___Feverish ___Dry skin
___Pre-menstrual irritability ___Sweat easily ___Dull, dry hair
___Thirst ___Thirst
___Cough ___Constipation ___Dry stools
___Asthma ___Red Face ___Scanty urine
___Nausea ___Sore throat or mouth ___Dry eyes and nose
___Vomiting ___Dark, scanty urine
___Belching ___Irritable Section 8: Feng
___Hiccups ___Preference for cold drinks ___Sneezing
___Preference for no blankets ___Clear runny nose
___Hemorrhoids ___Prefer cold air ___Aversion to drafts
___Organ Prolapse(sinking) ___Head and body aches
___Chronic diarrhea ___Cold body ___Nasal congestion
___Bearing down sensation ___Cold limbs ___Chills & fever
___Low sex drive
___Chronically tired ___Spasms
___Desire to sleep a lot ___Tremors
___Retaining water ___Dizziness, vertigo
___Preference for warm drinks ___Stroke
___Always sleep with a blanket ___Bells palsy
___Prefer warm air ___Convulsions
Section 9: Shi Section 14: Pi Section 19: Wei
___Heavy feeling ___Low appetite ___Stomach ulcer
___Bloating & Swelling ___Diarrhea ___Stomach pain
___Nausea ___Abdominal bloating ___Acid regurgitation
___No thirst ___Nausea ___Nausea
___Milky discharge ___Bleed easily ___Vomiting
___Loose stools ___Bruise easily ___Swollen, painful gums
___Weight gain ___Organ prolapse ___Bad breath
___Frequent worrying ___Always hungry
Section 10: Tan
___Fullness in chest Section 15: Shen Section 20: UB
___Coughing up mucus ___Painful low back ___Painful, burning urination
___ Frequently clearing throat ___Weak low back ___Bladder stones
___Decreased appetite ___Painful knees ___Kidney stones
___Wheezing ___Weak knees ___Cloudy urine
___Dizziness ___Poor vision ___Bloody urine
___Poor hearing
Section11: Fei ___Incontinence
___Coughing ___Nocturnal emission
___Asthma ___Frequent urination
___Shortness of breath ___Sexual dysfunction
___Chest fullness ___Hair loss
___Chest pain ___Bone weakening
___Wake up between 3-5 am ___Infertility
___Sadness & Grief ___Poor memory
___Frequently fearful
Section 12: Xin
___Palpitations Section 16: LI
___Anxiety ___Constipation
___Insomnia ___Burning Anus, Rectum
___Vivid dreaming ___Hemorrhoids
___Chest pain
___Left arm pain Section 17: SI
___Tongue sores or ulcers ___Abdominal pain
___Hysteria ___Burning urination
___Forgetfullness ___Bearing down sensation in groin
Section 13: Gan Section 18: Dan
___Pain in ribs ___Right side trunk pain
___Pain in sides of trunk ___Jaundiced skin
___Frequent anger ___Bitter taste in mouth
___Frequent depression ___Alternating chills & fever
___Migraine headache ___Nausea
___Vertigo ___Vomiting bitter fluids
___Ringing in ears ___Easily frightened
___Red or painful eyes ___Indecisive
___Poor vision ___Insomnia
___Poor nail growth
Painful areas: Mark with xx's
Numb, tingling areas: Mark with oo's
Pulse: _____________________________________________
Tongue: ____________________________________________
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