Acupuncture Intake Form - Redefined Health printable pdf download

ACUPUNCTURE PATIENT INTAKE FORM

PATIENT INFORMATION

Name:_____________________________________________________________________Date:______________________

Age:____________Weight:__________ Height:__________ Female :____ Male:____ Birth Date (dd/mm/yr):____________

Address:______________________________________________________________ Postal Code: ____________________

Home Ph:_______________________Cell Ph: ________________________ Work Ph:_______________________________

Email:_________________________________________ Occupation:____________________________________________

How did you hear about the clinic?

_____________________________________________________________________________________________________

PRIMARY CONCERNS/COMPLAINTS:

1.___________________________________________________________________________________

2. ___________________________________________________________________________________

3.___________________________________________________________________________________

OPERATIONS AND HOSPITALIZATIONS

DATE

DIAGNOSIS

PROCEDURE

CURRENT MEDICATIONS/SUPPLEMENTS:

NAME

DOSE/FREQUENCY

REASON

PAIN:

Have you consulted a physician/dentist about the condition for which you are currently seeking treatment? Yes No

What caused the pain (brief summary)? ____________________________________________________

How long ago did the pain begin? _________________________________________________________

Was the onset sudden or gradual? _________________________________________________________

Does the pain interfere with your daily activities? ____________________________________________

On a scale of 1 – 10 how would you rate your pain currently? (1 being lowest 10 being highest) _______

How would you describe the pain? (eg. shooting, stabbing, burning, throbbing, aching)

_____________________________________________________________________________________

Is the pain constant or does it come and go? ________________________________________________

What activities make it worse? ___________________________________________________________

What helps to alleviate the pain? __________________________________________________________

Please mark the location of your pain, following the legend on the next page.

Acupuncture Intake Form - Redefined Health