New Patient Intake Form
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3New Patient Form
Name:
Date of Birth:
Address:
Postal Code:
Home Phone:
Cell Phone:
Emergency Contact (name and phone #):
Have you been treated by acupuncture or Traditional Chinese Medicine before? Y □ N □
Are you currently under the care of other health care providers? Y □ N □
If yes, please list:
Main Health Concerns
Details of Concern (when did it begin, what is it associated with, what makes it
better or worse)
Medications or
Please indicate areas of pain or discomfort
Supplements
on image below:
Please note any drugs,
hormones, supplements
you take regularly
Injuries, Traumas or
Surgeries
Please note what,
where and when
Do you follow a special diet?
Habits
Amount
Quit
Sugar
□
Y □ N □ Type?
Caffeine
□
Do you exercise regularly?
Tobacco
□
Y □ N □ Type?
Other
□
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