Acupuncture Intake Form Page 2

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Personal Medical History 
 
(Please include your childhood history)
 
Illnesses 
 
 
 
Surgeries 
 
 
 
Significant Trauma: (i.e. motor 
 
vehicle accidents, fractures, etc.) 
 
 
Do have a history of current or past 
 
infectious disease? Please describe 
 
 
Medicines (please list all 
 
medications, herbs, vitamins and 
over the counter drugs) 
Allergies/Sensitivities (Please list any 
 
foods, drugs, medications or 
environmental factors which you are 
sensitive or allergic to) 
 
General (please check all that apply)  
 Poor Appetite 
 Weakness 
 Sudden Energy Drops 
 Hearing Loss 
 Fevers 
 Chills 
 Easy to Bleed or Bruise 
 Sweat Easily 
 Fatigue 
 Strong Thirst 
 Poor Sleep 
 Tremors 
 Puffiness or Swelling 
 Poor Balance 
 Weight Loss 
 Night Sweats 
 Cravings 
 Weight Gain 
 Changes in Appetite 
 Other: 
  
 
Skin & Hair  
 Rashes 
 Itching 
 Dandruff 
 Skin Ulcers 
 Eczema 
 Hair Loss 
 Hives 
 Pimples 
 Recent Moles 
 
Head, Eyes, Ears, Nose, and Throat  
 Dizziness 
 Toothache 
 Blurry Vision 
 Cataracts 
 Ear Ringing 
 Sinus Problems 
 Taste/Smell Problems 
 Headaches 
 Concussions 
 Eye Strain/Pain 
 Night Blindness 
 Poor Hearing 
 Nose Bleeds 
 Facial Pain 
 TMJ Pain 
 Migraines 
 Ear Aches 
 Spots in Front of Eyes 
 Recurrent Sore Throat 
 Lip or Tongue Sores 
 Floaters 
 
 
Cardiovascular  
2 

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