Health History Intake Form
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2ACUPUNCTURE
Health History Intake Form
Name: ________________________________________
Phone: (H) ________________________________
(W) ________________________________
DOB: _________________________________________
(C) ________________________________
Email: ________________________________________
Address: _______________________________________
City: _________________
Prov: _________
Postal Code: ____________________________________
Family Doctor: _____________________________
Occupation: ____________________________________
Employer: _________________________________
MSP CareCard#: ________________________________
How did you hear about us? _______________________________________________________________________
**Ask about our referral program to save on your next visit.
What is your primary reason for seeking treatment. Note dates, previous treatment and results if relevant.
___________________________________________________________________________________________________________
Previous illness: ______________________________________________________________________________________________
Surgeries: ___________________________________________________________________________________________________
Traumas (accidents, falls, scars, emotional traumas inc.): ____________________________________________________________
Allergies (food, drugs, etc.): ____________________________________________________________________________________
Current medications or supplements (drugs, vitamins, herbs, etc.): _____________________________________________________
Describe any work or home related stress: _________________________________________________________________________
Describe frequency and type of exercise: __________________________________________________________________________
Do you consume or use:
Caffeine
Alcohol
Recreational Drugs
Soda
Cigarettes
Does anyone in your immediate family have or have had any of the following:
Kidney Disease
TB
Thyroid Problems
Cancer
Ulcers
Heart Disease
Asthma
High Blood Pressure
Mental/Emotional Disorders
What emotions do you most commonly fee?
Fear
Worry
Joy
Anger
Calm
Sadness
Indecision
Other:_________________________________
For women only:
Age menstruation began:______________ ended: ______________ length of cycle: _______________
Painful
PMS
Clotting
Are you taking HRT or BCP?
Are you pregnant? ______________ How many months?______________
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Parent category: Business