Acupuncture Intake - Patient Information Form Page 2

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Acupuncture Intake
Basic Information
Name ___________________________________
________________ Date ________________
Address___________________________________________________________________________
City ___________________________________ State _____________ Zip code ______________
Telephone # (home)______________________ ________ (work) ___________________________
(cell)________________________________ Email Address _______________________________
Age _______ Date of Birth _________ Gender _______
How did you hear about our clinic?_____________________________________________________
Emergency Contact: Name____________________________ Relationship_____________________
Phone ______________________________
Are you currently under the care of a medical professional?
Y N
If yes, whom and where from?________________________________________________________
If no, when and where did you last receive medical or health care and for what reason? __________
_________________________________________________________________________________
What are your most important health concerns? List in order of importance.
1) _________________________________________________________________________
2) _________________________________________________________________________
3) _________________________________________________________________________
4) _________________________________________________________________________
5) _________________________________________________________________________
General Information
Weight___________lbs. Height____________________
Significant Traumas (auto accidents, falls, etc) ________________________________________
Birth history (prolonged labor, forceps delivery, etc)____________________________________
Occupational Stresses (chemical, physical, psychological)________________________________
Exercise______________________________________________________________________
Please list any prescription medications, over the counter medications, vitamins, or supplements you are currently taking or
have taken within the past 2 months:
1)_____________________________
2)____________________________
3)_____________________________
4)____________________________
5)_____________________________
6)____________________________
Do you have allergies? If yes, what kind?
Drugs _______________________________________________________________
Foods_______________________________________________________________
Environmentals________________________________________________________
What hospitalizations or surgeries have you had?
___________________________ year:_______ __________________________ year:_______
__________________________ year:_______ _________________________ year:_______
PATIENT NAME:_____________________________________________________
PATIENT DOB:____________________________
KWAN-YIN HEALING ARTS CENTER
2330 NW FLANDERS ST. SUITE 101
PORTLAND, OR 97210
PH: 503.701.8766
FAX: 503.241.5484

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