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Need a Personal Telephone or E-mail Consultation?

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 icon at the top of this page and fill out the intake form below. Fax your completed form to (831) 429-0103 with your credit/debit number and date of expiration. You may also copy and paste the intake form and This email address is being protected from spambots. You need JavaScript enabled to view it. The fee is $150 per incident. Cancer consult fee is $250. For telephone consultations call: (831) 429-8066 to make an appointment. Students currently enrolled in the East West School of Herbology receive a 20% discount on fees, mention that you are a student when you make your appointment.








Date of birth

Height and weight

Marital status



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:

Indicate 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 type & 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:

For Men and Women:

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:






If possible 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 photos please mail them to:

East West Acupuncture Clinic, 912 Center St., Santa Cruz, CA 95060

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