Anchor Point Acupuncture New Patient Intake

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

MonthDayYear
2 digit month, 2 digit day, 4 digit year
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
Employer
Home address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency contact name
Emergency contact number
Please enter a valid phone number.Format: (000) 000-0000.
Chief Complaints
Primary complaint or concern 1
Frequency 1
How long has this been happening?
Primary complaint or concern 2
Frequency 2
How long has this been happening?
Primary complaint or concern 3
Frequency 3
How long has this been happening?
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
Bleeding duration
Average cycle length
Date of last menstrual 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
Treatment history

Other
Surgeries
Current treatment from another provider
Medications
Allergies
Other health conditions
Diet and Lifestyle
Typical diet

Other
Diet notes
Fluid intake

Other
Water per day
Caffeine per day
Exercise and Movement
Exercise activities

Other
Lifestyle Habits
Lifestyle habits

Other
Alcohol use
Tobacco or vaping use
Treatment goals
Anything else?
Ready to Submit
Should be Empty:

New Patient Intake

Patient Information

Chief Complaints

Symptoms

Sleep and Stress

Health History

Diet and Lifestyle

Exercise and Movement

Lifestyle Habits

Ready to Submit