Confidential New Patient Intake
Dr. Mary Elizabeth Micari, DAc, LAc Tuning the Human Instrument for Health and Performance
I. Patient Information
- Name: _________________________________________________ Date: _______________
- Occupation: ____________________________________________________________________
- Are you a Union Member? (IATSE, AEA, SAG-AFTRA, etc.): _____________________________
- Main Reason for Visit (Your “Chief Complaint”): _______________________________________
- When did this begin? ___________________________________________________________
II. The Urban Landscape: Stress & Lifestyle
Living in New York City requires a unique level of resilience. Please rate the following on a scale of 1–10 (1 = Low, 10 = High):
- Daily Stress Level: [ ]
- Pace of Life (Feeling rushed/overwhelmed): [ ]
- Exposure to Environmental Noise/Pollution: [ ]
- How many hours do you sleep on average? _______ Is it restful? [Yes / No]
- Do you have difficulty falling asleep or staying asleep? _____________________________
III. The Performer’s Profile: Vocal & Physical Health
Complete this section if you are a vocalist, actor, or stage professional.
- Vocal Health: (Check all that apply)
- [ ] Vocal fatigue after performing
- [ ] Chronic throat clearing/phlegm
- [ ] Jaw tension (TMJ) or teeth grinding
- [ ] “Audition nerves” or performance anxiety
- [ ] Tightness in the diaphragm or chest
- Physical Demands (For Crew/Stagehands):
- Primary areas of physical pain: _________________________________________________
- Have you had any repetitive strain or “load-in” related injuries? _____________________
IV. The Internal Environment (TCM Indicators)
This information helps Dr. Mary prepare for your herbal consultation.
- Temperature: Do you tend to feel: [ ] Chilly [ ] Hot [ ] Hot flashes/Night sweats
- Digestion: Do you experience: [ ] Bloating [ ] Acid reflux [ ] Irregularity
- Energy: What time of day is your energy at its lowest? ________________________________
- Thirst: Do you prefer: [ ] Cold drinks [ ] Room temp/Warm drinks [ ] No thirst
V. The Second Spring & Vitality (Hormonal Health)
For patients seeking support for hormonal transitions or reproductive health.
- Are you currently experiencing changes in your cycle or transition into menopause? [Yes / No]
- Top 3 concerns (e.g., mood, bone density, temperature regulation, sleep):
- ____________________________ 2. ____________________________ 3. ____________________________
VI. Medical History
- Current Medications & Supplements: _____________________________________________
- Major Surgeries or Traumas: ____________________________________________________
- Allergies (Latex, Metal, Herbs, etc.): ____________________________________________
VII. Informed Consent & Policies
- 24-Hour Cancellation Policy: I understand that appointments cancelled with less than 24 hours’ notice will result in a forfeited session or full charge.
- Package Refunds: I acknowledge that unused package sessions are refunded at the Standard Rate ($110) minus a $35 Administrative Fee.
- Clinical Results: I understand that Traditional Chinese Medicine is a cumulative process and results vary by individual.
Signature: _________________________________________________ Date: _______________
M Center Acupuncture and Wellness 