New Patient Intake & Health History
Jing Well Clinic ~ Jonathan H Edwards, LAc.
Gender assigned at birth:
XXY or other
Please list your health concerns. Include subjective brief, precise descriptions of each complaint and the rough date when the complaint began (e.g. "burning pain in the upper abdomen worse after eating, began in 2013, worse since India travel summer 2016")
Give your health history in reasonable detail, including major illnesses, chronic conditions, surgeries, mental-emotional concerns. Include subjective detail wherever relevant.
What do you eat in a typical day? (If highly variable, indicate that and list what you ate yesterday)
How is your appetite? (e.g. dull, inconsistent, sharp)
BM frequency & consistency (e.g. "twice daily, formed to slightly loose"):
Any GI symptoms (e.g. gas, nausea, stomach pain)?
Thirst level (e.g. very thirsty, or have to remind self to drink water):
How is urination? Give approximate, frequency, color, and any concerns such as dribbling or unpleasant odor.
Sweating: Describe how easily you break a sweat and anything else you've noted about your tendencies with respect to sweating (Any night sweats? Sweating from certain parts of the body only?)
Prescription medications and dosages:
Vitamins, herbs, supplements:
Known allergies (foods, medications, etc):
Sleep - give bedtime, wake time, notes on sleep quality and interruptions:
Do you tend to run warm or cool, subjectively speaking? What kind of weather do you prefer?
Number of pregnancies:
Number of children, and years they were born:
Menses - overall cycle length (e.g. 26 27 days)
Describe flow, including heaviness, color, consistency, and presence of clots:
Describe any pain/cramping associated with cycle, and any PMS symptoms:
How would someone who knows you well describe you? Be fair but precise (e.g. 'intenselydriven, hard on myself, quick to get excited but quick to tire and needs to eat frequently or I turn into a screaming demon')
How do you respond to stress, typically? Describe both physical and emotional patterns.
Please state your goals for yourself and your health at this time.
Knowing yourself, and considering that food is one of the core pillars of health, how open are you to making dietary changes?
East Asian herbal formulas are traditionally administered in the form of decoctions, i.e. concentrated herbal teas. Other options include granulated herbs (instant tea) and, in some cases, capsules. Knowing yourself, how open are to preparing and taking a potentially funky tasting herbal brew daily for a period of weeks to months? There is no right answer, this info will simply help me gauge which delivery method is most appropriate for you.
Please use the remaining space to tell me anything else you feel I should know.
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