Acupuncture Intake Form

1
How did you hear about us? (please select from below)
Friend or Family Member
Search Engine
Yelp
Vagaro
Social Media
Walk-in
2
Name* This field is required.
First Name
Last Name
3
Preferred NameDo you prefer to be called something other than your legal name?
Preferred Name
4
Birth Date
Date of Birth
Year
Month
Day
5
What Gender do you identify as?
6
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
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Aruba
Australia
Austria
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The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
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Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Phone Number* This field is required.
Area Code
Phone Number
8
Email
example@example.com
9
Primary Physician
First Name
Last Name
Email
Phone
City
10
Other Pertinent Physician
First Name
Last Name
Email
Phone
City
11
MedicationsPlease list any Medications you are currently taking, including supplement + over the counter
12
Medical TreatmentsPlease list any recent Surgeries or Medical treatments you have received
13
Are you Pregnant?
Yes
No
I'm not sure
14
What do you hope to achieve during your visit?
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15
Please name 3 main areas of concern regarding your health + nutrition that you would like us to focus on
First area of concern
Second area of concern
Third area of concern
16
Can you recall the last time you felt well?
I feel well now
Within the last week
Within the last month
Within the last 3 months
Within the last 6 months
Over a year ago
Other
17
Did something trigger your change in health?
YESNO
18
Please explain
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19
What makes you feel worse?
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Ok
20
What makes you feel better?
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21
Please choose all conditions that apply to you or your parents
Acne
ADD/ADHD
Adrenal Disorders
Alzheimer's/Dementia
Arthritis/Joint Inflammation
Asthma
Autoimmune Disease
Cancer
Chronic Sinusitis
Digestive Disorders
Eczema
Elevated Cholesterol
Environmental/Food Allergies
Fatigue Syndromes
Female Disorders
Fibromyalgia
Headaches
Heart Disease
Insomnia
Mercury or Heavy Metal Toxicity
Metabolic Sundromes
Memory Problems
Migraines
Mood/Behavior Disorders
Multiple Sclerosis
Osteoprosis
Parkinson's Disease
Psoriasis
Restless Leg Syndrome
Thyroid Problems/Inbalances
Other
22
Is there anything else you would like to say about your health?
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23
What types of exercise do you regularly engage in?
Stretching/Yoga
Cardio/Aerobics
Strength Training
Sports/Leisure
Other
24
Please note any problems you have that limit your physical activity
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Sources of daily Stress + JoyPlease rate how each area in your life makes you feel
Work
Family
Relationships
Finances
Health
Education
Physical Activity
Overall
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Work
Family
Relationships
Finances
Health
Education
Physical Activity
Overall
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How easily do you handle stress?
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Do you wake up during the night?
YESNO
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How would you rate the quality of your sleep?
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Willingness to changeIn order to improve your health, how willing are you to make changes in these areas?
Modify your diet
Keep a food journal
Take supplements
Regularly exercise
Get more sleep
Meditate
Lessen work load
Have lab tests
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Modify your diet
Keep a food journal
Take supplements
Regularly exercise
Get more sleep
Meditate
Lessen work load
Have lab tests
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What do you think would make the most difference in your overall health?
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Food + DietPlease list some food you typically eat in a normal day
Breakfast Foods
Lunch Foods
Dinner Foods
Other Common Foods
32
Are there any foods that you avoid?
Meat
Seafood
Dairy
Gluten
Sugar
Caffeine
Corn
Nuts
Soy
Other
33
How many servings of Fruits + Vegetables do you get daily?
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How many glasses of Water do you drink daily?
35
Notice of Privacy Practices* This field is required.The privacy of your medical information, as described in the HIPPA Privacy Act, is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. We may use medical information about you to doctors, nurses, technicians, medical students or other health care providers to assist them in treating you. We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information. All patient information is handled under the HIPPA Privacy Act - Confidential HIPPA approved form. Your signature acknowledges that you understand.
Clear
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Informed Consent* This field is required.I hereby request and consent to the performance of the following diagnostic techniques and treatment modalities of oriental medicine on me (or the patient named below, for whom I am legally responsible) by any licensed doctor of Oriental Medicine credentialed by Gambei: acupuncture and other oriental medicine procedures; pulse evaluation; manual palpation on a variety of areas of my body; muscle, orthopedic and neurological testing; modes of physical therapy such as massage, heat/cold therapy, electrical and/or magnetic stimulation; the prescription of herbal and homeopathic medicines, as well as dietary supplements, exercise regiments and lifestyle counseling.I have had the opportunity to discuss with a doctor of Oriental Medicine the nature and purpose of acupuncture, including the procedures and treatment protocols associated with oriental medicine. I understand that, although acupuncture and other medical procedures have helped millions of people, no guarantee of cure or improvement in my condition is given or implied.I understand and am informed that, as in the practice of conventional medicine, in the practice of Oriental Medicine there are some risks of treatment. I understand that while unlikely, possible risks include, but are not limited to: bleeding, bruising, pain or other strong sensations at the location of needle insertion, nerve pain, aggravation of current symptoms, appearance of new symptoms, puncture of organs, and burns. I do not expect the doctor to be able to anticipate and explain all risks and complications, and during course of treatment I wish to rely on the doctor's judgment, based on the facts then known.I have read or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below, I agree to the above named procedures. I intend for this consent form to cover the entire course of treatment for my present condition and any future condition(s) for which I seek treatment.
Clear
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Notes
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Client Notes
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