Need a Personal Telephone or E-mail Consultation?Dr. Michael Tierra is a California state licensed acupuncturist with an O.M.D. (Oriental Medical Doctor's Degree) and founder of the American Herbalists Guild. He has been in clinical practice for approximately 30 years and is available for private on-line health, nutritional and/or herbal consultations. Clients are provided with a comprehensive, individualized dietary and herbal program based upon their presenting condition. In some instances a follow-up consultation may be recommended to evaluate the suitability or to adjust their program and evaluate their progress. Lesley Tierra is a California state licensed and nationally certified acupuncturist and herbalist. She has a practice in Santa Cruz, California where she combines acupuncture, herbs and food therapies along with lifestyle and inner growth counseling. She is a founding and professional member of the American Herbalists Guild. Print using the print or PDF icon at the top of this page and fill out the accompanying intake form and email to
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and/or fax to (831) 429-0103 with your credit/debit number and date of expiration. The fee is $150 per incident. Cancer consult fee is $250. For telephone consultations call: (831) 429-8066 to make an appointment. Specify either Michael or Lesley Tierra for your consultation.
Please provide the following information and e-mail or fax your response: Intake form Name Address Gender Telephone/fax Email Date of birth Height and weight Marital status Children Occupation Nearest relative Hobbies and special interests: Physical activities you engage in: Philosophical or religious affiliation (optional): How or from whom did you hear about us?: Medical doctor or other practitioner: Please list all medications, including herbs and vitamins you are presently taking, or therapies you are presently undergoing: Have you ever undergone herbal therapy before? Do you generally respond well to medical treatments, medicines, therapies, etc.?
A. PRIMARY COMPLAINT -- (Describe your symptoms to the best of your ability):
B. SECONDARY COMPLAINTS --- (List any other symptoms you are experiencing regardless of whether it seems related to your primary complaint): When did you first notice it? A __________ B __________ How long has is been occurring? A __________B __________ When and under what circumstances does it seem to improve? A __________B __________ Have you been treated by anyone else for this condition? A __________B __________ If so, when and by whom? Medical History (List all past illnesses, injuries and operations): Medical History of Relatives (Briefly): Grandparents, parents, Aunts/Uncles, Siblings, Children Blood Type? Ancestry? (What part of the world your parents/grandparents lived): Basal Temperature: (Take your temperature three mornings in a row, before rising, record average) Pulse Rate: Check if you have experienced any of the following conditions: If you have in the past, use a P, if recently use an R, if frequently also include an F. _____HBP _____Hypoglycemia _____Low Body Temp. _____LBP _____Epilepsy _____Gallstones _____Heart problems _____Nervous Complaints _____Kidney Stones _____Shortness of breath _____Spasms/twitches _____Hepatitis (specify A, B, C & dates) _____Asthma _____Bloatedness _____Carcinoma (specify location) _____Allergies _____Sleepiness after meals _____Cancer (specify location and type) _____Sinus infections _____Enlarged lymph nodes _____Low back pain _____Headaches _____Enlarged spleen _____Frequent urination _____Frequent colds & flus _____Enlarged Liver _____Night time urination _____Poor memory _____Mononucleosis _____Teeth problems _____Cold Hands and Feet _____Hearing Difficulties _____Thyroid Problems (specify) _____Undigested food in stools _____Constipation _____Eyesight difficulties _____Loose stools _____Depression _____Glandular problems (specify) _____TB _____Over-excitable _____Mood Swings _____Anemia _____Diarrhea _____PMS _____Diabetes _____Tight neck/shoulders _____Disability of hips _____Disability of back _____Disability of knees _____Disability of ankles _____Other (specify) For Women:What is the length of your menstrual cycle? What is the length of your menses itself? Do you ever experience PMS? Cramping? If so when? Clotting? Light flow? Excessive flow? List the dates and years of any children you have birthed and if they were normal delivery: How would you describe your energy level? High ___________ Low ___________ Up and down ____________ How would you describe your sex drive? High __________Low ___________ Up and down ____________ Do you get gas and/or bloatedness? How would you describe your elimination? Bowel Movements: Are they regular (daily) ___________ Consistency and color: ______________ Do they float or sink? __________ Mucus in the stools? _____ Urine: Is your urinary frequency more than 6x/day or less than 4x/day? Color __________Odor ______________ Other __________ _________ Do you experience night time urination? Number of times/night? How would you describe you sleep? Any recurring dreams? How is your memory? How would you describe the stress level in your life? Home _________ Work ___________ Other ______________ Do you have an unusual susceptibility to heat or cold? What temperature do you prefer in terms of climate and foods? What is (are) the predominant emotion(s) you experience? Are you content with your life? Home? Work? Social? Other? What are your strengths? What are your weaknesses? Please describe any emotional issues you have in terms of your family, work and social relationships: What special ambitions or desires do you have? Do you use alcohol, cigarettes, cola, sugar coffee, marijuana, cocaine or any other recreational drug? (specify frequency and quantity): Would you consider yourself to have a sugar, caffeine, nicotine or drug addiction? Do you have a strong preference for, or aversion to, any foods or drinks? (specify): What particular diet or nutritional program do you follow? (Example: vegetarian, macrobiotic, meat & potatoes, etc.) Do you generally cook your own food? Where do you shop for your food? Please describe your general diet: Breakfasts: Lunches: Dinners: Snacks: Drinks:
If possibly please send the following photos, which are very helpful towards your evaluation: Email a photo of yourself (mostly your face) and a photo of your tongue. If you do not have the technology to email the photo's please mail them to: East West Acupuncture Clinic, 912 Center St., Santa Cruz, CA 95060
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