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.
Date of birth
Height and weight
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
Ancestry? (What part of the world your parents/grandparents lived):
Basal Temperature: (Take your temperature three mornings in a row, before rising, record average)
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.|
|_____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)|
|_____Diabetes||_____Tight neck/shoulders||_____Disability of hips|
|_____Disability of back||_____Disability of knees||_____Disability of ankles|
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 ___________
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