Black Spruce Acupuncture Intake & Consent

Acupuncture Intake & Medical History
To assist you with the best possible care, please fill out this form as accurately as you can. All information provided will be kept confidential.
Personal & Contact Information
Full Name: *
Date:

Month Day Year
Date
Date of Birth *

Month Day Year
Date
Address:
City:
Province:
Postal Code:
Phone (home/cell): *
Phone (work):
Email: *
example@example.com
Emergency contact:
Medical Doctor:
Emergency contact number:
Gender: *
Height, Weight:
What forms of treatment/therapy do you currently or have you used?
Have you had acupuncture before? Y/N
Have you taken Chinese herbs before? Y/N
Occupation:
How did you hear about us?

Health History
Primary reason(s) for today's visit, in order of importance. Please include how long you've had it, how bad it is (1 10) what makes it better/worse, how it affects your sleep/work/relationships etc.:
Medical Diagnoses (by an MD):
Prescription drugs, over the counter drugs, supplements or herbs you are taking, and the condition you are taking them for:
Major accidents, illnesses, infections, birth traumas, surgeries, etc (include dental surgery and vaccinations):
Immediate family health history:
Please check any that apply:

Blood Thinners Possibility of Pregnancy Hemophiliac or other bleeding disorders Asthma Stroke Needle Sensitivity Seizure Disorder Scheduled Surgeries Pacemaker

Welcome to Black Spruce Acupuncture! I am delighted to have you as a new patient and look forward to providing you with the highest quality of care.
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Acupuncture Intake & Medical History