Initial Client Intake Form — Rainbow Medicine

Welcome

Initial Consultation Intake

Welcome to your Initial Consultation Intake Form

Hi there! This intake form will guide you through a series of questions about your health, lifestyle and treatment goals. The form auto-saves as you go, and you can resume later using the link sent to your email.

Your responses are confidential and used only by your practitioner to plan safe, personalised treatment.

Step 1 of ?

Personal Details

First name

Surname

Phone

Date of birth

Height (cm)

Weight (kg)

Gender

Male Female Non-binary / Other Prefer not to say

Pronouns

Address

Health fund

Occupation

Emergency contact

Full name

Relationship

Phone

GP / Family doctor

Doctor's name

Phone

How did you hear about us?

Google Instagram Facebook Family & Friends YouTube SMS / Email WhatsApp TikTok Other

Step 2

Main Health Concern & Safety

How would you describe your overall health?

Excellent Good Fair Poor

Main health concern (in your own words)

Duration

Frequency

What makes it better or worse?

Safety screen

On blood thinners?

Yes No

Pacemaker?

Yes No

Bleeding disorder?

Yes No

History of fainting?

Yes No

Pregnant or trying?

Yes No Not applicable

Past reaction to acupuncture?

Yes No

Anxiety around needles?

Yes No

Prior acupuncture treatment?

Yes No

Step 3

Medical History & Lifestyle

Significant medical history (conditions, surgeries, injuries)

Current medications & supplements

Allergies (medication, food, environmental)

Do you exercise?

Yes — regular Occasionally No / Inactive

Exercise detail

Caffeine intake

Smoking?

Yes No

Alcohol?

Yes No

Recreational drugs?

Yes No Prefer not to say

Working hours / week

Less than 20 hours 20–30 hours 30–38 hours More than 38 hours Retired / Not working

Occupational stress

Very stressful Moderately stressful Mildly stressful Not stressful Not applicable

Step 4

Diet & Digestion

Appetite

Poor Variable Good Excellent

Meals per day

Water intake

<1L 1–2L 2–4L >4L

Diet pattern (select all that apply)

Eats dairy Eats red meat Eats seafood Vegetarian Vegan Gluten-free Organic focus

Typical food on a normal day

Digestive symptoms

Bloating Nausea Pain Reflux Belching / Burping Excessive gas Vomiting Fully satisfied None of the above

Bowel symptoms

Constipation Diarrhoea Alternating Loose stools Mucus Bleeding Straining Haemorrhoids Flatulence Normal

Step 5

Sleep & Energy

Hours of sleep

<7 hrs 7 hrs >7 hrs

Falling asleep is...

Easy Moderate Difficult

Wake at night?

Yes No

On waking, you feel...

Refreshed Mostly rested Somewhat tired Very tired Exhausted

Sleep apnoea?

Yes No

Use CPAP?

Yes No

Vivid dreams?

Yes No Nightmares

Peak energy time

Lowest energy time

Step 6

Body Systems Review

Urinary symptoms

Frequency Urgency Burning or pain Dribbling / incomplete emptying Waking at night to urinate History of UTIs None of the above

Urine colour

Clear Light yellow Dark yellow Murky / cloudy Strong smelling

Respiratory & cardiovascular

Shortness of breath Asthma / wheezing Palpitations Chest tightness Chest pain Phlegm / mucus Sinus congestion Sinus allergies Vertigo / dizziness None of the above

Thermal sensations

Cold hands / feet Hot hands / feet Aversion to cold Aversion to heat Chills Night sweats / hot flushes None of the above

Eyes & ears

Tinnitus Ear pain / infections Blurred vision Dry eyes Floaters Night blindness None of the above

Pain (locations, duration)

Headaches?

Yes No

Mental health diagnosis?

Yes No

Mood swings?

Yes No

Emotional state

Anxious Stressed Irritable Sad / low Prone to worry Angry Fearful Generally positive Prefer not to say

Skin

Acne Eczema Psoriasis Rosacea Dermatitis Dry / flaky skin Excessive sweating Itching None of the above

Step 7 — ♂ Male

Men's Health

Concerns (select all that apply)

Low libido Erectile dysfunction Premature ejaculation Low sperm count Prostate concerns Testicular pain or masses Hernia STI history None of the above

Urinary stream

Hesitancy Weak flow Incomplete emptying Waking at night to urinate None of the above

Prostate status

No known concerns Elevated PSA Benign prostatic hyperplasia Prostatitis Other / unsure

Erectile dysfunction

No Occasionally Often Most of the time Prefer not to answer

Libido

Good / normal for me Reduced Very low Not applicable Prefer not to answer

Premature ejaculation

No Sometimes Frequently Prefer not to answer

Discharge / urethritis

No Yes — being treated Yes — not yet investigated Prefer not to answer

STI history

None known Past history (resolved) Current / under treatment Prefer not to answer

Testosterone

No Low testosterone suspected Currently on TRT Other hormone issue Prefer not to answer

Fertility / IVF relevance

Yes — actively trying to conceive Yes — currently in IVF/ART cycle Considering fertility support No — not relevant

Semen analysis done?

Yes — normal results Yes — abnormal results No Not applicable

Specific findings

Low count Low motility Abnormal morphology No sperm found DNA fragmentation None / normal Not tested

Other concerns

Step 7 — ♀ Female

Menstrual History

Age at first period (menarche)

Before 11 11 12–14 15 After 15 Not applicable

Cycle regularity

Very regular Mostly regular Irregular Very irregular Not applicable

Cycle length (days)

Bleeding days

Last menstrual period

Flow

Light Moderate Heavy Very heavy (flooding) Scanty / almost absent Not applicable

Blood colour

Bright red Dark red Dark brown / black Pale / watery Purple Contains clots Contains tissue / mucus Not applicable

Period pain (dysmenorrhoea)

None Mild Moderate Severe Debilitating Not applicable

Pain type / location

Cramping Stabbing Dull ache Lower back Radiating down thighs Responds to heat

PMS symptoms

Breast tenderness Irritability Anxiety Sadness Bloating Food cravings Headaches / migraines Water retention Acne flare-up Constipation / diarrhoea None / Not applicable

Menopause status

No — still menstruating regularly Perimenopause Currently in menopause Postmenopause Surgical menopause Not applicable

Menopause symptoms

Hot flushes Night sweats Vaginal dryness Mood swings / irritability Anxiety or depression Brain fog Sleep disturbance Joint aches Weight changes Reduced libido Hair thinning Palpitations None

HRT use

No Yes — HRT (conventional) Yes — bioidentical Previously used — stopped Considering it

Bone density

Not tested Normal (DEXA) Osteopaenia Osteoporosis diagnosed

Ovulation signs

Pelvic twinge / pain Clear egg-white discharge Increased libido Breast tenderness Bloating mid-cycle No noticeable symptoms Not applicable

Step 8 — ♀ Female

Gynaecological History

Diagnosed conditions

PCOS Endometriosis Uterine fibroids Uterine polyps Uterine prolapse Adenomyosis Ovarian cysts Pelvic Inflammatory Disease High prolactin Premature ovarian insufficiency Thyroid disorder Hashimoto's / autoimmune None of the above

Cervical history

Abnormal Pap smear Cervical biopsy Cervical cauterisation LLETZ / cone biopsy None of the above

Contraception

Oral contraceptive pill Depo Provera Mirena / hormonal IUD Copper IUD Implant Other / none

Pain with intercourse

No Yes — mild Yes — significant Not applicable

Thyroid status

No thyroid issues Hypothyroidism Hyperthyroidism Hashimoto's thyroiditis Graves' disease Under investigation

Libido

Good / normal for me Reduced Very low Prefer not to answer

Vaginal dryness

No Mild Moderate / significant Not applicable

Yeast / thrush

Never / rarely Occasionally Frequently (3+/year) Currently present

STI history

None known Past history (resolved) Current / under treatment Prefer not to answer

Step 9 — ♀ Female

Obstetric & Fertility History

IVF / fertility relevance

Yes — currently doing IVF/ART Yes — actively trying Considering in the future Supporting partner's IVF No — not relevant

Seeing a gynaecologist?

Yes No

Recent pelvic ultrasound?

Yes No

Pregnancies

Live births

Miscarriages

Terminations

Currently pregnant?

Yes No Not sure

How long have you been trying?

AMH tested?

Yes No

Other hormone tests?

Yes No

Male factor

No known issue Male factor identified Under investigation Single / not applicable Prefer not to say

Partner's semen analysis?

Yes No Not applicable

ART treatments

Ovulation induction IUI IVF ICSI FET Egg freezing Donor egg None

ART history details

Active fertility cycle?

Yes No

Fertility specialist

Current fertility supplements

Blood & Lab Results

Upload Blood Test Results

Click to upload or drag & drop

PDF, JPG, PNG, DOCX — max 10 MB each

Test summary

Key results

Goals

Your Treatment Goals

What would you like to focus on?

Pain management Stress & anxiety Sleep improvement Digestive health Hormonal balance Menstrual regulation Natural conception support IVF / ART support Recurrent miscarriage Energy & fatigue Immune support General wellbeing Other

What do you hope to achieve?

How would you measure success?

Special considerations

Preferred contact method

SMS Email WhatsApp Phone call

Preferred contact time

Morning Afternoon Evening Any time

Final Step

Consent & Signature

Consent declaration

By submitting this form I confirm the information provided is accurate to the best of my knowledge. I understand that Rainbow Medicine will use this information solely to plan safe, personalised treatment and will keep it confidential per Australian Privacy Principles.

I have read and accept the consent declaration above.

Printed name

Date