Intake Form - Cait Donovan Acupuncture & Burnout Coach
This is the first step in booking your appointment time with Caitlin Donovan, Dipl. O.M., Expert in Chinese Medicine with a focus on Burnout and Stress Management. Please allow yourself 15 minutes to fill in the form completely as you cannot save it and continue at another time. Your answers will be read and reviewed before your appointment time.
Full Name *
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Age *
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Birthdate *
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Phone Number *
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Email *
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Prefered Pronouns
Please tell me about your main complaint(s): physical, mental, and emotional - including a short history and a Western diagnosis where applicable.
Your answer
What makes your symptoms better? Worse?
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What is the source (are the sources) of your stress?
Your answer
What do you do for rest? Describe the quality of your rest.
Your answer
True or False: You tend toward people pleasing
True or False: You feel underappreciated
True or False: You don't feel a sense of control
On a scale of 1-10, 10 being fried to a crisp, how burnt out are you right now?
What regenerates you, if anything?
Your answer
What unhealthy habits do you use to get away from burnout (i.e., drinking, rec drugs, overeating, sugar, binge watching, scrolling)?
Your answer
What healthy habits do you have ALREADY in place?
Your answer
List: Medications, Supplements, Herbs, Adaptogens
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Safety: Please note any food allergies or intolerances
Please list any past surgeries (throughout your entire life)
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Do you experience pain on a monthly or more regular basis? If yes, please mark the body part affected
Tightness
Swelling
Sharp Pain
Dull Pain
Pressure
Heavy Pain
Neck
Shoulder
Upper Back
Lower Back
Hips
Knees
Ankles
Feet
Hands
Wrists
Muscle
Sleep
Waking Up
How many coffees do you have per day?
Your energy level throughout the day
Temperature
Cool
Cold
Neutral
Warm
Hot
Body
Hands / Arms
Feet / Legs
Weather I dislike
Amount of Sweat
Skin Disorders
Skin: Please expand upon any dermatological issues noted above (i.e., location, frequency, intensity)
Your answer
Head
Daily
Frequently
Occasionally
Almost Never
Never
Headaches
Migraines
Dizziness
Vertigo
Poor Memory
Clouded Thinking
Lightheadedness
Heaviness
Eyes
Ears
Nose
Mouth
Throat
Chest:
Thirst
Thirst
Room Temp Beverages
Cold Beverages
Warm/Hot Beverages
I prefer
Appetite
Abdomen
Diet
Urination
Urination
Bowel Movements
Bowel Movements
Emotional Wellbeing
Women: Menstrual Cycle
Women: Menstrual Cycle
Women: Menstrual Cycle
Women: Gynecology
Women: Gynecology, Menopause
Women: Gynecology Please use this space for any concerns not listed above
Your answer
Men: Andrology
Male: Andrology Please use this space to share any concerns not listed above
Your answer
Additional Space
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