Phw Acupuncture Intake Form
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4PHW ACUPUNCTURE INTAKE FORM
Today’s date:
______
NAME: __________________________________________
Primary Health Concerns
How long have you had it?
1)
2)
3)
4)
What kinds of treatment have you tried?
List any medications (including over-the-counter), vitamins, and herbs you are currently
taking.
Do you tend to have reactions to medicine?
______________
Do you have any metal implants or a pacemaker? _____________
List any surgeries, car accidents, and significant trauma (physical or emotional) in your life:
Do you smoke?
Do you follow any particular diet?
Do you exercise?
How often?
Type of exercise:
How much do you drink alcohol: never
rarely
socially
more than 3 times a week
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