Acupuncture Intake form
Name
First Name
Last Name
Telephone (Home/Mobile)
Please enter a valid phone number.
Telephone (Business)
Please enter a valid phone number.
Gender
Male
Female
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Marital Status
Occupation
Email
example@example.com
Family Contact Information (In case of an emergency)
First name
Last name
Relationship to patient
Phone Number
Please enter a valid phone number.
Family Doctor Name
Family Doctor Phone Number
Past Medical History - Please list any relevant past medical history including any hospitalizations, surgeries, prior injuries, or any past medical conditions etc. Be sure to include any previous family medical conditions or diseases that may be relevant.
Ongoing Health Conditions?/Allergies/Drug Reactions/Risk Factors/Long Term Treatment. Please list any ongoing health conditions, allergies, drug reactions, and long term treatments that may be relevant. If you are currently taking any prescription medications, please include them.
Current symptoms
Please check off any conditions you are experiencing (past and present):
General symptoms
Headaches/migraines
Fever
Chills
Sweats
Memory loss
Dizziness/light headedness
Fainting
Stress/depression
Discoordination
Nervousness
Recent weight loss/gain
Numbness pain in arms, legs
Cardiovascular
High or low blood pressure
Previous stroke or TIA
High cholesterol
Swelling of ankles
Poor circulation
Stroke/heart attack
Irregular heartbeat
Shortness of breath
Pain over heart
Respiratory
Wheezing
Chronic cough
Spitting up phelgm
Chest pain
Difficulty breathing
Muscle and Joint
Stiff neck
Back ache
Swollen joints
Painful tailbone
Pain in shoulder
Hernia
Spinal curvature
Faulty posture
Arthritis
Foot trouble
Genitourinary System
Frequent/painful urination
Blood in urine/stool
Mucus in stool
Kidney infection/kidney stone
Bladder infection
Inability to control urine
Ears, Eyes, Nose, Throat
Hearing loss
Vision problems
Glaucoma
Ringing in ear(s)
Crossed eyes
Eye pain
Deafness
Earache
Ear discharge
Nose bleeds
Nasal obstruction
Sore throat
Hoarseness
Hay fever
Asthma
Dental decay
Gum trouble
Frequent colds
Enlarged thyroid
Tonsilitis
Sinus infection
Nasal drainage
Enlarged glands
Skin
Skin conditions/rashes
Itching
Bruise easily
Dryness
Boils
Varicose veins
Sensitive skin
Hives or allergy
Gastrointestinal
Poor apetite
Distress from greasy foods
Excessive hunger/thirst
Belching or gas
Nausea
Vomiting
Burning in stomach
Pain over stomach
Constipation/diarrhea
Colon trouble
Liver trouble/hepatitis
Gall bladder
Ulcers
Colitis
Hemorrhoids
Hiatal hernia
Metallic taste
Hypoglycemia
For Women Only
Cramps/backache
Previous miscarriage
Irregular cycle
Vaginal discharge
Lumps in breast
Menopausal symptoms
Pregnant
Painful menstruations
Excessive flow
Hot flashes
Hysterectomy
Have you had any of the following?
Appendicitis
Diabetes
Epilepsy
Pneumonia
Mumps
Pneumatic fever
Malaria
Venereal infection
Multiple sclerosis
Measles
Influenza
Arthritis
Chicken pox
Cold sores
Anemia
Goiter
Gout
Rubella
Alcoholism
Whooping cough
Heart disease
Eczema
Polio
Parkinson's
Osteoporosis
Cancer
Tuberculosis
Mental illness
Pleurisy
HIV/AIDS
Signature of patient or Substitute Decision-maker
Relationship to patient
Date
-
Month
-
Day
Year
Date
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