Intake Form

We ask that you complete a brief western medicine intake form. This enables us understand your current symptoms and past history. For more complex issues and for internal medical conditions, we ask that you also complete a second slightly longer Chinese medicine intake form. This helps us to more accurately understand your unique situation and to prescribe customized herbal preparations. To save you time and to help you understand your unique signs and symptoms from both a western medicine and Chinese medicine perspective, both the short intake and long intake forms can be completed prior to your visit.

Do this by opening the form, placing an "x" next to the appropriate boxes.

• Western Medical History Intake Form
• Chinese Medicine Intake Form

Or you can call or email and we will e-mail them to you.

How to send the forms

1. Save the form with your added information
2. In Word, there is a "Send" button under the File menu. That will automatically open an email with your completed form as an attachment.
3. Enter your name in the email subject line.
4. Enter steve@stevepaineomd.com as the email address and send it
5. Or you can open your email directly and attach the form

We highly recommend your completing both intake forms prior to your first visit . We also recommend the educational advantages of reviewing this website prior to your first visit.

Steve Paine, OMD 540 Hopmeadow St., Simsbury, CT 06070 T: 860 970 4232 steve@stevepaineomd.com

Copyright 2008-2010 Steve Paine, OMD, All rights reserved website by prairiecomm

Albert Place Practice 1103 Luk Yu Building, 24-26 Stanley Street Central Hong Kong yinyang@appractice.com