Calgary Acupuncture – Southcentre Chinese Acupuncture

Functional Medicine Intake Form

General information

Please list two major health issues that you’d like me to help with:
Time of first started
Any therapies tried (please list)
Any medication or supplements tried (please list)
Triggering factors

Your diet

Please let me know about your diet (if you eat less then 3 meals, just put N/A on the 3rd meal session)
1st meal
2nd meal
3rd Meal
Other meals
Water intake
Other liquid
Wake up time
Exercise (how often, what kinds)
Bowel Movement per day


(Score: 0—not at all, 10–very bad)
Stressed out
Sleep Apnea
Memory loss
Brain fog
Attention deficient
Mood swings
Bloating or cramps or pain in the stomach
Heart burn
Frequent or painful urination
Shortness of breath
Muscular and/or skeleton pains
Hot flashes
Night sweats

Woman’s Health

Do you have regular menstrual cycle (Y/N)
1st day of last period
How many pregnancy
How many kids
How old is your youngest child
Any BCP or hormonal IUD in your whole life (Y/N)
Any hormonal treatment in your whole life (fertility, HRT or hormone blocker)
Are you currently on BCP or hormonal IUD, if yes, please indicate what kind
Are you currently on any hormonal treatment, if yes, please indicate what kind
PMS (0: none; 10: strong)
Libido (0: none; 10: normal )

Your relationships

How do you rate your workplace relationships (0: very bad; 10: very good)
Do you think your workplace relationship affects your health (Y/N)
How do you rate your household relationships (0: very bad; 10: very good)
Do you think your household relationship affects your health (Y/N)
Are your health concerns caused by an emotional trauma (Y/N)

Other information

Do you contact chemicals at work? (Y/N) If yes, what are they
Do you drink tap water? (Y/N) If yes, how much per day
Did your house have water damage before (Y/N)
Is your house near major high way
Is your hobby involving contacting chemicals, if yes, what kind
Were you naturally born or through C-session
Were you breast fed
How many rounds of antibiotics have you had in your whole life
Most recent TSH
Most recent HbA1C
Consent for Functional & Nutritional Medicine Evaluation and/or Treatment
Signature of patient*

Please fill in all the necessary fields before submitting the form.  Upon successful submission, you will be taken to a “Thank You” page with a confirmation message.

In case of difficulty, please email us at [email protected] or call us at 403-271-6662.