Acupuncture Intake form

Acupuncture Intake form
Name

First NameLast Name
Telephone (Home/Mobile)
Please enter a valid phone number.Format: (000) 000-0000.
Telephone (Business)
Please enter a valid phone number.Format: (000) 000-0000.
MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
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.Format: (000) 000-0000.
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):
Headaches/migrainesFeverChillsSweatsMemory lossDizziness/light headednessFaintingStress/depressionDiscoordinationNervousnessRecent weight loss/gainNumbness pain in arms, legs
High or low blood pressurePrevious stroke or TIAHigh cholesterolSwelling of anklesPoor circulationStroke/heart attackIrregular heartbeatShortness of breathPain over heart
WheezingChronic coughSpitting up phelgmChest painDifficulty breathing
Stiff neckBack acheSwollen jointsPainful tailbonePain in shoulderHerniaSpinal curvatureFaulty postureArthritisFoot trouble
Frequent/painful urinationBlood in urine/stoolMucus in stoolKidney infection/kidney stoneBladder infectionInability to control urine
Hearing lossVision problemsGlaucomaRinging in ear(s)Crossed eyesEye painDeafnessEaracheEar dischargeNose bleedsNasal obstructionSore throatHoarsenessHay feverAsthmaDental decayGum troubleFrequent coldsEnlarged thyroidTonsilitisSinus infectionNasal drainageEnlarged glands
Skin conditions/rashesItchingBruise easilyDrynessBoilsVaricose veinsSensitive skinHives or allergy
Poor apetiteDistress from greasy foodsExcessive hunger/thirstBelching or gasNauseaVomitingBurning in stomachPain over stomachConstipation/diarrheaColon troubleLiver trouble/hepatitisGall bladderUlcersColitisHemorrhoidsHiatal herniaMetallic tasteHypoglycemia
Cramps/backachePrevious miscarriageIrregular cycleVaginal dischargeLumps in breastMenopausal symptomsPregnantPainful menstruationsExcessive flowHot flashesHysterectomy
AppendicitisDiabetesEpilepsyPneumoniaMumpsPneumatic feverMalariaVenereal infectionMultiple sclerosisMeaslesInfluenzaArthritisChicken poxCold soresAnemiaGoiterGoutRubellaAlcoholismWhooping coughHeart diseaseEczemaPolioParkinson'sOsteoporosisCancerTuberculosisMental illnessPleurisyHIV/AIDS
Signature of patient or Substitute Decision-maker

Clear
Relationship to patient
Date

MonthDayYear
Date
Should be Empty:

Acupuncture Intake form

Family Contact Information (In case of an emergency)

Current symptoms