Anchor Point Acupuncture New Patient Intake

Anchor Point Acupuncture New Patient Intake

Tiffany Tuftee L.Ac., Dipl. O.M., QME. Welcome to Anchor Point Acupuncture. Thank you for choosing us for your care. Please take a few moments to complete this intake form thoroughly and honestly. Your responses help us better understand your condition, tailor your treatment, and provide you with the most effective care possible. All information is kept strictly confidential.
Patient Information
Full name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Occupation
Employer
Chief Complaints
Area 1- Primary complaint or area of concern
Frequency 1
How long Have you experienced this?
Area 2- Primary complaint or area of concern
Frequency 2
How long have you experienced this?
Area 3- Primary complaint or area of concern
Frequency 3
How long have you experienced this?
Symptoms

Please click any of the following symptoms you have experienced now or in the past.
Immunity
Digestive / Bowel / Bladder

Other
Neuro-Adrenal

Other
Circulation

Other
Mind / Spirit

Other
Chronic Pain
Sexual Health

Other
Women's Menstrual Health

Other
Date of last menstural period?
How many days do you bleed? ___ days
Average cycle length: ___ days? (Cycle length = Day 1 of one period → Day 1 of the next period)
Sleep and Stress
Hours of Sleep
Sleep Quality

Other
Stress Level

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Health History
Have you received treatment for your current condition before? Click all that apply

Other
Surgeries
Are you currently receiving treatment from another provider? If yes, type of treatment/provider:
Medications
Allergies
Comorbidities (other diagnosed conditions or health concerns — e.g., cancer, hypertension, diabetes, autoimmune disorders)
Diet and Lifestyle
Typical Diet

Other
Diet Notes
Fluid Intake

Other
Water (cups per day)
Caffeine (servings per day)
Exercise and Movement
Exercise Activities.

Other
Lifestyle Habits
Lifestyle habits

Other
Alcohol use
Tobacco or vaping use
Treatment goals: What would you like to achieve through treatment?
Anything else? Additoinal information you would like your practitioner to know?
Ready to submit? Review your answers above, then click Submit, to send your intake form securely to Anchor Point Acupuncture. You'll see a confirmation when it goes through.
Should be Empty:

Anchor Point Acupuncture New Patient Intake

Patient Information

Chief Complaints

Symptoms

Sleep and Stress

Health History

Diet and Lifestyle

Exercise and Movement

Lifestyle Habits

Ready to submit? Review your answers above, then click Submit, to send your intake form securely to Anchor Point Acupuncture. You'll see a confirmation when it goes through.