New Patient Form

Date of Birth *
Name *

First Name Last Name
Email *
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Date *

Month Day Year
What are you coming in to treat? *
Please list any medications or supplements you are taking
Do you have digestive issues? (list below)
What is your day to day stress level 1-10?
Food or seasonal Allergies? (list below)
Do you have any Issues with Eyes, ears, nose or throat? (list below)
Do you regularly feel hot, cold or normal?

Hot Cold Normal
Are you experiencing pain anywhere (list below)
Do you get headaches/migraines? (if yes, please list known causes and location and area of the head)
Do you?

Drink more than you feel is healthy Smoke cigarettes Smoke marijuana Do hard drugs Eat poorly (fried foods, fast food, excess sugar etc)
Do you experience heart palpitations?
Do you experience?

numbness or tingling radiating nerve pain cold hands cold feet numbness or loss of feeling
Women's Issues

Irregular cycle clots painful prior to period painful ovulation light flow heavy flow very dark very light continuously spotting low libido menopause Other
Previous surgeries or major injuries?
Is there anything else you'd like to add?
History of

depression anxiety disorder manic disorder personality disorder
Men's issues

low libido prostatitis low sperm count
Privacy Policy:

I understand Oceanpoint Acupuncture will maintain my health records for 7 years as is required by law.

I may request a copy of my records at any time.

I have the right to deny use of my medical records unless requested in a court of law

My information will be kept secure and private with all HIPPA compliancy

Financial Policy:

There is a 24 hour notice of cancellation. If this is not given I understand I will be charged hald the cost of the session.

Disclosure

I understand that acupunctre may cause bruising, skin irritation and occasional dizziness. Will notify Gabe Schiff-Verre if I am pregnant at any time.
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