Cup of Life Healing Center TCM Intake

New Patient Forms
Welcome to Cup of Life Healing Center. We are so glad to meet you.

Important Information about this form:
- Please submit this form at least 24 hours prior to your consultation.
- We suggest allowing approximately 30 minutes time to complete this form.
- Please take your time and be as detailed and accurate as possible.
- Your complete and detailed history gives us a clear window into addressing the underlying patterns and root cause of what is going on.
- The more specific you can be, the better. The more information we have, the more accurately we can assess and treat your case from a holistic perspective.
- When you submit the form, make sure you see a "Thank You" page. If you do not, scroll back up the form and fill in any missing information (highlighted in red) and then resubmit.
Thanks so much and we look forward to meeting you soon!
WHAT IS THE MAIN REASON YOU ARE SEEKING HELP?
I am seeking help with:*

Chronic Health Issue or General WellnessWomen's Health/Hormonal WellnessFemale Fertility (non-IUI / non-IVF)Female Fertility (IUI / IVF / FET)Male Fertility
PATIENT INFORMATION
Patient Name*

First NameLast Name
Pronouns
Email*
example@example.com
Home Phone*
Please enter a valid phone number.
Mobile Phone*
Please enter a valid phone number.
May we send text reminders for your appointments?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
Date
Current Age:*
Sex (assigned at birth)*

FemaleMale
Gender*

FemaleMaleNeutralOther
Relationship Status*

SingleMarriedPartneredDivorcedWidowedOther
Relationship Status (old)
Number of Children*
Age(s) of Children
e.g. 5, 10, 12
Employer*
Occupation*
Personal Physician's Name*
When was your last complete medical exam?*
Emergency Contact Name*
Emergency Contact Phone*
Please enter a valid phone number.
Emergency Contact's Relation to You*
Have you had acupuncture before?*

YesNo
Have you had acupuncture before? (old)
Name of doctor or friend that referred you (if applicable):
How did you hear about us?*

Friend/Loved OneDoctorGoogleFacebookFree SeminarDiscussion ForumOther
How did you hear about us? (old)
WHAT YOU'RE SEEKING HELP WITH?
Describe what you would like us to help you with:*
How long have you had this problem?*
What types of treatment have you or are you receiving for it?*
If you're receiving treatment, tell us the doctor's/practitioner's name:
Recently the condition has:*

Not ChangedWorsenedImproved
What makes it better?*
What makes it worse?*
Anything else you think we should know about the problem you are seeking help with?*
FERTILITY HISTORY
How long have you been trying to get pregnant?*

Less than 6 months6-12 months1-3 yearsMore than 3 years
How long have you been trying to get pregnant? (old)
Check any diagnosis you've received from a fertility specialist:

Blocked tubesDiminished ovarian reserve (Low AMH)EndometriosisFibroidsHigh FSHPCOSPoor egg qualityPremature ovarian failure/insufficiencyUnexplained infertilityUterine abnormalitiesOther
Check any treatments you've done so far:

AcupunctureDonor eggs / embryosIVF (In-Vitro Fertilization)IUI (Intrauterine insemination)Nutrition / Functional MedicineOral medication (clomid / femara / letrozole / etc)Other
Check all tests/procedures you're aware of that have been performed within the last 12 months:

AMH levelsFSH/LH levelsHSG (x-ray with dye to check tubes)HysteroscopyLaparoscopyProlactin levelsThyroid levelsUltrasound of ovariesUltrasound of uterine cavityOther
If you are receiving fertility treatment, which clinic are you working with?
If you're receiving fertility treatment, tell us the doctor's/practitioner's name:
Partner's semen analysis results (if male partner):*

Not testedPoorGoodExcellent
Partner's semen analysis results (if male partner): (old)
Number of pregnancies:*

012345+
Number of births:*
Number of pregnancies: (old)
Anything else you think we should know about your fertility situation / journey?
MALE FERTILITY HISTORY
How long have you been trying to get pregnant?*

Less than 6 months6-12 months1-3 yearsMore than 3 years
How long have you been trying to get pregnant?
Check any diagnosis you've received from a fertility specialist:

Low countLow motilityLow morphologyVaricoceleAzoospermiaTesticular failureUnexplained infertilityOther
Check any treatments you've done so far:

AcupunctureDonor eggs / embryosHormone injectionsIVF (In-Vitro Fertilization)IUI (Intrauterine insemination)Nutrition / Functional MedicineOral medication (clomid / femara / letrozole / etc)Testicular aspirationVaricocele surgeryOther
Check all tests/procedures you're aware of that have been performed within the last 12 months:

FSH/LH levelsSemen analysisTestosterone levelsTesticular ultrasoundThyroid levels
If you are receiving fertility treatment, which clinic are you working with?
If you're receiving fertility treatment, tell us the doctor's/practitioner's name:
Partner's tubes are (if female partner):

Not testedBoth openOne openBlocked
Anything else you think we should know about your fertility situation / journey?
Partner's tubes are (if female partner): (old)
MEDICAL SUMMARY
Height:*
Weight (now):*
Weight (1 yr ago):*
Weight (max):*
Describe your height/weight: (old)*
List medications, supplements you're taking (or enter "none" if none):
List medications, supplements you're taking (or enter "none" if none). Include: Name of Medication or Supplement, Dosage, and Reason Taken*
List any major accidents, injuries, or surgeries and when they took place (or enter "none" if none):
List any major accidents, injuries, or surgeries and when they took place (or enter "none" if none). Include type of injury or surgery and when it occurred.*
List known food, drug, or environmental allergies (or enter "none" if none):*
PERSONAL AND FAMILY MEDICAL HISTORY
Check all in your FAMILY history (i.e. siblings, parents, grandparents, etc.):*

ArthritisAnxietyAsthmaAutoimmune DiseaseBowel IssuesCancerChronic Skin ConditionsDepressionDiabetesDementiaHIV /AIDSHeart AttackHeart DiseaseHigh Blood PressureInfertilityKidney DiseaseLiver DiseaseLow Blood PressureMental IllnessOsteoporosis / OsteopeniaSTDStrokeUlcerNone of the AboveOther
Check all in your YOUR history:*

AllergiesAnemiaArthritisAnxietyAsthmaAutoimmune DiseaseBowel IssuesBreast LumpCancerBleeding DisordersChronic Skin ConditionsDepressionDiabetesDementiaHIV /AIDSHeart AttackHeart DiseaseHigh Blood PressureInfertilityKidney DiseaseLiver DiseaseLow Blood PressureMental IllnessOsteoporosis / OsteopeniaSTDStrokeUlcerNone of the AboveOther
Is there anything else you would like us to know about your personal health history or your family's health history?
MENSTRUAL HISTORY
Age of Onset of Menstruation:
Age of menopause (if applicable):
Describe any symptoms you experienced associated with menopause (if applicable):
Date Last Period Started:

MonthDayYear
Cycle length (from period day 1 to next period day 1):
Period flow length (number of days of flow):
Cramping:

NoneMildModerateSevere
Cramping (old):
Color of Flow:

Normal redDark redLight redOther
Flow Amount:

NormalLightHeavyExtremely LightExtremely Heavy
Color of flow: (old)
Flow amount: (old)
Check all that apply:

Lots of clotsLots of tissueMid-cycle bleeding / spottingSpotting more than 1-2 days prior to periodSpotting more than 2 days after end of periodTired during/after periodSevere mood swings before or during period
If you track ovulation, how do you track it? (check all that apply):

Basal Body Temp (BBT)Ovulation predictor kit (home urine test strips)App on my phoneDon't trackOther
Do you ovulate regularly?

YesNoNot sure
Cervical mucus with ovulation is:

NormalScantyExcessiveAbsentNot sure/don't check
Do you ovulate regularly? (old)
Cervical mucus with ovulation is: (old)
Are you pregnant or could you be pregnant?

YesNo
Are you trying to become pregnant?

YesNo
Number of Pregnancies:

012345+
Number of Births
Number of pregnancies: (old)
Anything else you want us to know about your cycles / period / ovulation?
CURRENT SYMPTOMS PROFILE

Describe any symptoms or habits you have currently or have had recently.
Major Source of Stress (#1)*
Major Source of Stress (#2)*
Major Source of Stress (#3)*
Major Sources of Stress: (old)
Energy level is generally:*

Very lowLowNormalHighVery High
Check all that apply:

Energy fluctuates a lot during the dayFrequent sleepiness after mealsSudden burst of energy in the eveningVery tired in the morning
Energy level is generally: (old)
If you have energy lows during the day, what time do they occur?
If you have energy highs during the day, what time do they occur?
Sleep is generally:*

TerribleNot greatPretty goodAwesome
Sleep is generally: (old)
Regarding sleep, Check all that apply:

Difficult to fall asleepDifficult to stay asleepDifficult to wake upRestless sleepFrequent wakingWake up and difficult to fall backWake up to urinate multiple timesNightmaresVivid dreamsNight sweatsToo hot/coldOther
Typical bedtime*

Hour Minutes

AM/PM Option
Typical Wake time*

Hour Minutes

AM/PM Option
Number of times you wake up during the night:*
Total # hours of sleep:*
Mood is generally:*

SadIrritable/AngryI'm Pretty ChillExcited/UpbeatErraticWorriedAnxious/Nervous
Mood is generally: (old)
Do you often feel (check all that apply):

AngerAnxietyBipolarDepressionFearfulFrustratedHopelessIrritableOverwhelmedPanicResentfulSadnessStressedWeepyWorried
Body Temp Sensation:*

Often feel warm/hotOften feel cold/chillFluctuatesNormal/Stable
Body Temp Sensation: (old)
Regarding Body Temp, check all that apply:

Cold hands and feetFrequent sweatingHot flashesNight sweatsWarm hands and feet
Bowel Habits:*

1-3 times dailyMore than 3 times daily3-5 times a weekLess than 3 times a week
Bowel Habits: (old)
Check all that apply for digestion/bowel movement:

Acid RefluxBelching / Bloating / gasCeliac / Gluten SensitivityColon troubleConstipationCramping / urgencyDiarrheaDifficulty swallowingDistention of abdomenExcessive hungerFullness after mealsGallbladder issuesHemorrhoidsIBSIndigestionNauseaPain over stomachPoor appetiteVomitingOther
Urinary habits:*

Less than 3 times a day4-6 times a day6-8 times a dayMore than 8 times a day
Urinary habits: (old)
Check all that apply for urination:

Blood/pus in urineBurningDischarge of pus or blood from penisErection difficultiesFrequent urinationFrequent urinary tract infectionsInability to control urineKidney infection/stonesLow spermcount/motilityLowered libidoOveractive bladderPainProstate issuesUrgencyVery dark colorOther
Check all that apply for muscles/joints/bones:

CrampingTremorsOther
Pain, weakness, numbness in:

ArmsBack of legsFeetHandsHipsNeckShouldersOther
Eyes/Ears/Nose/Throat/Respiratory:

Asthma/wheezingBlurred or failing visionDifficulty breathingEaracheEnlarged glandsEye painFrequent coldsHay feverHoarsenessGum troubleNose bleedsLoss of hearingPersistent coughRinging in earsSinus problemsOther
Cardiovascular:

Chest painHardening of arteriesHigh blood pressureLow blood pressurePain over heartPoor circulationPrevious heart attackRapid/irregular heartbeatSwelling of ankles/legs/feetOther
Skin:

BoilsBruise easilyDry skinItching/rashSensitive skinSores that won't healSweating
Check any symptoms you have had in the last year:

Allergy/sinus issuesAnemiaAnxietyBreast lumpChronic coughDepressionDifficulty in FocusingDizziness / LightheadednessEasily startledExcessive angerExcessive fearExcessive worryFaintingFatigue/TirednessFrequent colds/fluHeadachesHeart palpitations/irregular heartbeatJoint/spinal problemsLoss or gain of weightLoss of sleep or poor sleepLoss of taste/smellMuscle weakness/sorenessNails soft or break easilyNervousness/irritabilityOverwhelmed by lifeSeizuresShortness of breathSwelling in legs/feet
Check all conditions that you have had in the last year:

Allergy/sinus issuesAnemiaAnxietyArthritisAuto-Immune Dis.Bleeding disorderBreast lumpCancerChronic coughConcussionDepressionDiabetesEar/hearing problemsEye problemsFrequent colds/fluHeadachesHeart attackHeart diseaseHeart palpitations/irregular heartbeatHepatitisHigh blood pressureHigh cholesterolHigh/low thyroidHIV/AIDSJoint/spinal problemsLow blood pressureParalysisSkin disordersSTDsStrokeTuberculosis
Is there anything else you would like us to know about your current symptoms?
GENERAL HABITS
Do you smoke?*

YesNo
If yes to smoking, how much in a day?
Alcohol?*

YesNo
If yes to alcohol, how much in a week? What type?
Coffee or Tea?*

YesNo
If yes to coffee/tea, how much in a day? Decaf or regular?
Exercise?*

NeverLittleModerateHeavy
List Types of Exercises you do, including frequency and duration:*
EATING HABITS
Do you follow any type of special diet?

VegetarianVeganGluten FreeLow FatKosherKetoOther
Describe time and types of foods you eat for breakfast:*
(e.g. "Eggs, oatmeal, cereal, 7am")
Describe time and types of foods you eat for lunch:*
(e.g. "Salad, sandwich, leftovers, 12 noon")
Describe time and types of foods you eat for dinner:*
(e.g. "7 pm, chicken, fish, rice, vegetables")
Describe time and types of snacks you eat:*
Describe food cravings. What types of food do you crave and at what time of day?*
Informed Consent
I understand that Cup of Life Healing Center does not provide primary care medicine and that I am responsible to seek primary health care from a qualified medical doctor.

Acupuncture is a safe method of treatment, but may have side effects including slight pain or discomfort at the insertion site, bruising, and rarely temporary dizziness or faintness. Unusual risks of acupuncture include infection, although this clinic uses sterile disposable single-use needles, maintains a clean and safe environment, and adheres to the principles of clean technique.
I have the following conditions (check all that apply):*

PregnancyBleeding disordersLocal infectionsUse of anticoagulantsPacemakerI do NOT have any of the above conditions
Choose ONE:*

It is okay to share information with my physician.Please do not share information with my physician.
I understand the risks and I voluntarily consent to the above procedures.
Signature* Date*
CLINIC POLICIES AND SIGNATURE
In order to maintain the quality of care at the clinic, we have instituted a number of policies, which are outlined below. By signing this form, you agree to abide by these policies:

Diversity: Cup of Life Healing Center does not discriminate based upon age, gender, race, religion, sexual orientation, health status, or the ability to pay. We hope you will join us in honoring diversity.

Confidentiality: I agree to maintain the confidentiality of all other patients of the clinic. Our staff will maintain your confidentiality by not acknowledging you outside of the clinic unless you first acknowledge them.

Privacy Policy: In accordance with HIPAA (Health Insurance Portability and Accountability Act) regulation and New Hampshire Law, Cup of Life Healing Center takes the right to your privacy seriously. Therefore, we do not disclose any personal, health, financial, or any other information about you or the services we provide to you to any third parties without your request or permission. This also includes online services we provide, including access to your appointment information, user-ID, or password.

As healthcare practitioners and administrators, we are also responsible for staying up-to-date with HIPAA regulations and for properly training all staff members and new employees to ensure that your personal health information is not compromised. If at any time you have a concern or complaint about your privacy, please contact Cup of Life Healing Center’s privacy officer or the Office of Civil Rights of the US Department of Health and Human Services.

Appointment reminders: As a courtesy to you, we make every effort to email or text with an appointment reminder one day before each scheduled appointment. If for some reason we do not remind you, the no-show policy still applies if you fail to arrive for your appointment.

Identifying Information: I understand that any published research will not contain identifying information and that my medical record will not be released without my written consent.

Needle safety: During acupuncture, I agree to remain lying down during treatment and not to remove or manipulate the acupuncture needles.

Etiquette: I agree not to come into the clinic under the influence of alcohol or non-prescribed drugs. I agree to turn any cell phone/pager to silent mode. I agree to respect other patients’ relaxation and will keep conversation to a minimum when in the treatment room. I understand that if my behavior does not comply with the policy of the clinic that I may be refused or released from treatment by Cup of Life Healing Center until I agree to comply.

Release of Liability for Lost or Stolen Goods: Cup of Life Healing Center is not responsible for lost or stolen goods. Please do not bring valuables into the treatment room. We cannot guarantee their safety.

Payment: I understand payment is expected at the time of visit. Cup of Life Healing Center accepts cash, check, credit card, debit card as well as FSA or HSA cards. We do not accept insurance but will be happy to provide you with documentation of your treatment that you may file with your insurance company.

Cancellations: We ask for at least 24-hour advance notice if it is necessary to cancel an appointment. All appointments that are canceled with less than 24-hour advance notice, and appointments missed without notice, will be charged the minimum amount for that appointment service. If appointments have been purchased in a package, the missed or canceled appointment will be deducted from the number of remaining appointments in that package. If you miss your appointment or are more than 10 minutes late, you can be seen as a walk-in by the same practitioner with whom you had your original appointment at the practitioner’s discretion. If you want to come later the same day and see a different practitioner, you must pay for both appointments.

I attest that the information provided is true and correct. By signing below, I agree to the policies, consents, and release of liability as set forth in the entirety of this document.
Signature* Date*
Should be Empty:

New Patient Forms

WHAT IS THE MAIN REASON YOU ARE SEEKING HELP?

PATIENT INFORMATION

WHAT YOU'RE SEEKING HELP WITH?

FERTILITY HISTORY

MALE FERTILITY HISTORY

MEDICAL SUMMARY

PERSONAL AND FAMILY MEDICAL HISTORY

MENSTRUAL HISTORY

CURRENT SYMPTOMS PROFILE

GENERAL HABITS

EATING HABITS

Informed Consent

CLINIC POLICIES AND SIGNATURE