Acupuncture Intake

Acupuncture Intake Form
Name
Birth date

MonthDayYear
Date
Date

MonthDayYear
Date
Emergency Contact Name
Emergency contact number
Please enter a valid phone number.
Is this visit due to an accident

YesNo
If an accident please describe
When did symptoms start?
Rate your level of pain from 1-10
How often do you have pain?
Does the pain come and go?
Has the pain gotten:

BetterWorsestayed the same
Do your symptoms interfere with any of the following:

WorkSleepExerciseChores
Is it painful to:

WalkRunSitStandBendLay down
Medications
Allergies
Vitamins/Supplements
Exercise Level

NoneModerateHeavyDailyWeekly
Work activity

SittingStandingLight LaborHeavy Labor
Do you smoke? If yes how often per day?
Do you drink alcohol? If yes how often per day/week?
Do you drink caffeine (coffee/soda/energy drinks/tea)? If yes, how often?
Are you or could you be pregnant?
Please list any injuries/ surgeries and dates:
Please Mark Yes or No to the Following:
Please check if you have any of the following:

Aids/HIVAlcoholismAllergy shotsAnemiaAnorexiaAppendicitisArthritisAsthmaBleeding disordersBreast lumpBronchitisBulimiaCancerCataractsChicken poxDiabetesEmphysemaEpilepsyGlaucomaGoiterGonorrheaGoutHeart DiseaseHepatitisHerniaHerniated DiskHerpesHBPHigh CholesterolKidney DiseaseLiver DiseaseMeaslesMigrainesMononucleosisMononucleosisMSMumpsOsteoporosisPacemakerParkinson'sPinched NervePneumoniaPolioProstatePsychiatricRASTDStrokeThyroid IssuesTonsillitisTuberculosisUlcersInfectionsCough
Please share any additional information/questions you may have
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Acupuncture Intake Form