Tao Acupuncture Clinic Intake Form
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1Tao Acupuncture Clinic Intake Form
Personal Information
Name:
M/F:
Address:
City:
State:
Zip:
Phone:
Email:
DOB:
Age:
History
How is your diet?
Any issues with sleep?
Do you exercise regularly?
Have you received acupuncture before?
What is your major complaint?
Previous complaints/surgeries/medications:
Do You Have Any of the Following? (Check All That Apply)
Severe Pain
Constipation/ diarrhea
Inflammation
Skin Rash
Headache
IBS
Insomnia
Cold or Flu
Asthma
Incontinence
Pregnancy
Arthritis
Diabetes
Varicose Veins
PMS/Menopause
Stomach Ulcers
Hemophilia
Dizziness
Cancer
Pins/Pacemaker
Depression
High/Low Blood Pressure
Heart Disease
Other________________
Anxiety
Allergies
Musculoskeletal Problems
________________
Mark Areas of Discomfort
Tao Acupuncture Clinic does not share personal health information. By signing below I voluntarily consent to
be treated with acupunture, massage, refelxology, chinese herbs, and oriental medicine by a licensed
professional. I have read consent for treatment and will make practitioner aware of any pain or discomfort. I
understand that I am aware of possible risks and side effects and I may stop treatment at any time.
Signature
Date
How did you hear about us?__________________________________________________________________
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