AcupuncturePatient Intake Form

Legal Name: / Date of Birth: / Gender: / Identifies as:
Preferred Name: / DD/MM/YYYY / Occupation:
Address: / City: / Postal Code:
Tel: / Alt. Tel: / e-mail:
Emergency Contact: / Tel: / Relation:
Name of Medical Doctor: / Doctor’s Address:
How did you find out about our clinic? / Sign  / Web Site  / Referral  Who? /
CHIEF COMPLAINT(S): / MEDICATION / Reason / Date Started / Dosage / Side Effects
1)
2)
3)
Other Treatments you are presently receiving:
Do you consume alcohol?  No  Yes ______drinks per week
Do you smoke? No Yes  Quit ______packs per week
DIET AND LIFESTYLE / Do you consume coffee?  No  Yes tea?  No  Yes soda?  No Yes
Please list any special dietary habits &/or restrictions:
What types of sports & physical activities do you do? How often?
Are your energy levels low/ average/ high/ fluctuating?
INTERNAL AND EXTERNAL
LOCATION OF PAIN / HEALTH HISTORY / Major illnesses in your family:
Please mark location of pain and discomfort / List all surgeries, injuries traumas and Date.
Allergies:
GYNECOLOGICAL:
Currently pregnant Y / N
First Period: / (YYYY) / Last Period: / (DD/MM/YYYY)
Menses Duration: / (days) / Cycle Duration: / (days)
Please Check All That Apply (C= Current, P=Past)
PMS /  C  P / Endometriosis /  C  P
Irregular Periods /  C  P / Infertility /  C  P
Painful Periods /  C  P / Low Sexual Drive /  C  P
Light Periods /  C  P / High Sexual Drive /  C  P
Heavy Periods /  C  P / Abnormal Discharge /  C  P
Fibroids /  C  P / Yeast Infection /  C  P
SKIN & HAIR / RESPIRATORY / URINARY / HEAD AND THROAT
Itching /  C  P / Cough /  C  P / Painful Urination /  C  P / Headaches /  C  P
Rashes /  C  P / Shortness of Breath /  C  P / Difficult Urination /  C  P / Migraines /  C  P
Eczema /  C  P / Bronchitis /  C  P / Frequent Urination /  C  P / Dizziness /  C  P
Psoriasis /  C  P / Emphysema /  C  P / Kidney Stones /  C  P / Vertigo /  C  P
Bruise Easily /  C  P / Pneumonia /  C  P / Kidney Disease /  C  P / Floaters /  C  P
Dry Skin / Scalp /  C  P / Asthma /Wheezing /  C  P / UTI /  C  P / Loss of smell /  C  P
Acne /  C  P / Dry Throat /  C  P
Sore Throat /  C  P
Tinnitus /  C  P
GASTROINTESTIONAL / CARDIOVASCULAR / MUSCULOSKELETAL / PSYCOLOGICAL & NEUROLOGICAL
Trouble Digesting /  C  P / Pacemaker / EMD /  C  P / Scoliosis /  C  P / Anxiety /  C  P
Nausea /  C  P / High Blood Pressure /  C  P / Bursitis /  C  P / Depression /  C  P
Ulcers /  C  P / Low Blood Pressure /  C  P / Tendonitis /  C  P / High Stress Level /  C  P
Constipation /  C  P / Heart Attack /  C  P / Sciatic Pain /  C  P / Low Stress Level /  C  P
Diarrhea /  C  P / Stroke / TIA /  C  P / Arthritis /  C  P / Seizures /  C  P
IBS /  C  P / Palpitations /  C  P / TMJ /  C  P / Epilepsy /  C  P
Crohn’s or Colitis /  C  P / Fainting /  C  P / Degenerating Disc /  C  P / Poor Sleep /  C  P
Hemorrhoids /  C  P / Haemophilia /  C  P / Osteoporosis /  C  P / Shingles /  C  P
Clotting Disorder /  C  P / Fibromyalgia /  C  P / Bell’s Palsy /  C  P
Chronic fatigue /  C  P
ANDROLOGICAL/
Men’s Health / OTHER
Enlarged Prostate /  C  P / Anemia /  C  P / Thyroid Problem /  C  P
Erectile dysfunction /  C  P / Loss of Sensation /  C  P / Cancer /  C  P
Low Sexual Drive /  C  P / Loss of Balance /  C  P / Hepatitis /  C  P
High Sexual Drive /  C  P / Edema / Swelling /  C  P / Diabetes /  C  P
Gallstones /  C  P / Tuberculosis /  C  P
Cholecystitis /  C  P / HIV /  C  P
Bad Breath /  C  P / Phlebitis /  C  P
Addiction /  C  P / Anything else?

Please Check All That Apply (C= Current, P=Past)