Phw Acupuncture Intake Form Page 2
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4MARK all areas of pain on the diagram
YOUR PAIN IS:
constant
comes & goes
numb
tingling
stabbing
dull
getting better
getting worse
PAIN GETS WORSE WITH:
cold
heat
movement
sitting / standing
rising from bed
end of the day
stormy weather
PAIN IMPROVES WITH:
cold
heat
Color or Highlight
massage / pressure
movement
All Areas of Pain
rest
ALLERGIES
List any allergies, intolerances, and sensitivities in the table below.
Do NOT include allergies to medications.
Things you EAT
Things you BREATHE
Things you TOUCH
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