Intake Form
Passage Wellness + Acupuncture
Date
-
Day
-
Month
Year
Date
Full Name
First Name
Preferred Name
Last Name
Preferred pronoun:
Birthdate
-
Day
-
Month
Year
Date
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
What is your gender?
Female
Male
Trans Man
Trans Woman
Non-binary
Gender-non-conforming
Prefer not to specify
Other
Emergency Contact
Name
Relationship
Phone Number
Have you received acupuncture previously?
Yes
No
Have you received somatic therapy previously?
Yes
No
How did you hear about me?
Health History
Operations, injuries, surgeries:
Allergies, drug reactions:
Medications, supplements, herbs, etc:
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
Heart disease
Allergies
Pacemaker
Hypertension/High blood pressure
Stroke
Low blood pressure
Bleeding disorder
High cholesterol
Anemia
Thyroid condition
Cancer
Seizure disorder
Substance use/addiction
Depression/anxiety
Other
Do you have any blood born or communicable/infectious diseases?
yes
no
If so, please indicate:
Main Complaint
What is your main complaint?
How long have you had this issue?
On a scale of 1-10, how intense is this issue? i.e how intense is the discomfort or how much does it impact your sense of wellbeing.
What makes it better? (temperature, movement, medications, other treatments, etc.)
What makes it worse? (temperature, movement, medications, other treatments, etc.)
Does this issue interfere with your?:
Work
Sleep
Activity/exercise
Relationships
Secondary Complaint
What is your secondary complaint?
How long have you had this issue?
On a scale of 1-10, how intense is this issue? i.e how intense is the discomfort or how much does it impact your sense of wellbeing.
What makes it better? (temperature, movement, medications, other treatments, etc.)
What makes it worse? (temperature, movement, medications, other treatments, etc.)
Does this issue interfere with your?:
Work
Sleep
Activity/exercise
Relationships
Other Health Factors
How do you sleep?
Trouble falling asleep
Trouble staying asleep
Vivid dreams and/or nightmares
Don't feel rested in mornings
How is your digestion?
Abdominal discomfort and/or pain
Abdominal bloating
Gas
Nausea
Heartburn
Belching
No appetite
Excessive appetite
How often do you move your bowels?
Do you move your bowels with ease?
Do you feel like you have enough energy to get through the day?
Do you get regular exercise? If so, explain:
Please rate your current stress level: Mild or none = 0; Severe = 10
Generally, the emotions I feel on a daily basis are:
Content
Joy
Sad
Grief
Depression
Numb
Anxious
Fearful
Irritable
Angry
Is there anything else you'd like me to know about?
Submit
Should be Empty: