Thank you for your interest in holistic healing!
We have 2 options to expedite the intake process and make your experience more enjoyable:
1. If you are able to download (right click and Save As), print, and bring this intake form with you to your appointment it will be very helpful. For option 2 please scroll down:
2. If that doesn't work for you you can copy and paste this form into a word document and bring it with you to your first appointment to help the intake process go most efficiently & effectively. Thank you for your cooperation!
Acupuncture Intake Form
Name ______________________ Date of Birth _______________
Phone ______________ email: ______________________
Address _____________________________________
- Primary reasons for acupuncture treatment:________________________________
- What surgeries/injuries/accidents have you had? Year? ___________________________________________________________________
- Please list any current or past major illnesses or other hospitalizations: __________ ___________________________________________________________________
- Medications and supplements:__________________________________________
__________________________________________________________________
- Emergency contact
____________________________________________________
Please check or circle any medical condition listed below
that currently applies to you:
“ Contagious skin condition
“ Open sores or wounds
“ Easy bruising
“ Recent accident or injury or surgery
“ Current fever / Swollen glands
“ Inflammation/ swelling/ edema
“ Allergies, rashes, or fungal infection
“ Sinusitis
“ Heart condition/ Stroke/ MI/ palpitations
“ Atherosclerosis/ High Cholesterol (TG)
“ High or low blood pressure
“ Circulatory disorder/ Anemia
“ Varicose veins/ Hemorrhoids
“ Emphysema/ Bronchitis
“ Asthma/ difficulty breathing
“ Insomnia
“ Depression/ Anger/ Irritability
“ Anxiety/ Poor memory/concentration
“ Joint disorder/ artificial joint/Dislocations
“ Arthritis or gout
“ Connective tissue disease
“ Osteoporosis
“ Tendonitis, bursitis
“ Muscle spasm or cramps
“ Sprains/ strains (location) ____________
“ Ringing in the ears
“ Jaw pain
“ Epilepsy
“ Headaches/ migraines
“ Infertility
“ Menopause/ PMS
“ Chronic fatigue/ Fibromyalgia
“ Cancer
“ Diabetes
“ Erectile Dysfunction
“ Decreased sensation/ neuropathy
“ Thyroid dysfunction
“ Hepatitis
“ HIV
“ Contagious condition
“ Constipation/diarrhea/ IBS/ gas/ abdominal
pain
“ Drug, alcohol, caffeine, or tobacco use
(circle and list frequency) _____________
Other Significant:
_____________________________________________________
____________________________________________________________________
I hereby consent to treatment.
I have listed all my known medical conditions and physical limitations
and will inform the acupuncture physician in writing of any change in my
physical health or insurance plan between sessions. I understand that my acupuncturist must be
aware of any and all existing physical conditions that I have in order to
provide an appropriate treatment. I also
understand that the acupuncturist will not diagnosis illness, disease, or any
other medical, physical, or emotional disorder.
I am responsible for consulting a qualified primary care provider for
any ailment that may I have. I agree to pay for missed services if I
do not give 24 hour notice of cancellation.
_________________________
_________________ _________________
Signature Name Date
Otherwise please arrive 15 minutes early to fill it out in person.
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