Initial Intake Form
Basic Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Nonbinary/Genderqueer
Height
*
Weight
*
Marital Status
*
Single
Married
Partnered
Divorced
Widowed
Occupation
*
Contact Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Introduction
What is the primary issue you'd like to address with acupuncture?
*
Any secondary issues you'd like to address?
How and when did these issues begin?
How much are these challenges impacting your day-to-day life?
Minimal impact
1
2
3
4
5
6
7
8
9
Worst impact
10
1 is Minimal impact, 10 is Worst impact
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General Health and Wellness
Current medications and/or supplements
Known allergies
Personal Health History (please select all that may apply)
Cancer
Hepatitis
Epilepsy or seizure disorder
Diabetes
Heart Disease
High Blood Pressure
HIV or AIDS
PTSD
Significant hospitalizations, surgeries, or accidents (if applicable)
Do you wear a pacemaker?
*
Yes
No
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Mind-Body Survey
Where in your body might you hold tension/stress? (choose all that may apply)
Neck and shoulders
Lower back and/or hips
Jaw and head
Chest and/or stomach
How might you rate your current level of stress (physical or psychological)
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
Do you regularly experience energy crashes at any point during the day? (Select all that may apply)
Early afternoon (1-3pm)
late afternoon (3-5pm)
After meals
Random times throughout the day
Frequent Temperature (select all that may apply)
Cold hands and/or feet
Hot flashes
Hot sensation in hands or feet
Frequent sweating
Night sweats
Frequent Emotions (select all that may apply)
Fear
Depression
Grief
Anxiety
Worry
Irritable
Anger
Manic
General Symptoms (select all that may apply)
Palpitations
Restlessness
Insomnia
Dizziness
Tremors
Loss of balance
Panic attacks
Upper Respiratory (select all that may apply)
Cough
Dry mouth, nose, or throat
Chills and fever
Sore throat
Frequent sinus congestion
Asthma
Seasonal allergies
Frequent shortness of breath
Digestion (select all that may apply)
Low appetite
Loose stools
Constipation
Diarrhea alternating with constipation
Abdominal bloating or gas after eating
Feeling tired after eating
Mental fogginess after eating
Acid reflux
Large appetite
Canker sores or cold sores
Heartburn
Vomiting/Nausea
Bleeding, swollen, or painful gums
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Women only
Are you currently pregnant?
Yes
No
Number of pregnancies
Number of live births
Age of first period
Age of last period (if applicable)
Is your menses cycle regular?
Yes
No
Average number of days in flow
The flow is:
Normal
Heavy
Light
The color is
Red
Dark
Purple
Light brown
Brown
Do you experience any of the following symptoms related to menstruations? (select all that may apply)
Blood clots
Cramps
Nausea
Breast distention
PMS
Heavy bleeding between periods
Heavy vaginal discharge between periods
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Is there anything else you'd like us to know?
Submit
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