Community Acupuncture Patient Intake Form

13531 Mayes Road • Huntersville, NC 28078
ph1 - 704.892.5002 • ph2 - 704.655.7324
cristin@wellbeingnaturalhealth.com
Full Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Occupation
Marital Status
E-mail
Family Physician

Primary Health Concerns
Condition
Past Treatment
How does this condition affect you?
What other health concerns do you have?
Stats
Height
Current weight
Past max weight
When?

MonthDayYear
Blood Pressure
Blood pressure when?

MonthDayYear
Cholesterol
Cholesterol when

MonthDayYear
Childhood Illnesses
Childhood illnesses
Allergies and Medications
If applicable, please list any foods, drugs, medications, or environmental factors you are hypersensitive or allergic to (please include reaction)
Should be Empty:

Primary Health Concerns