Acupuncture Intake - Patient Information Form Page 3

ADVERTISEMENT

Acupuncture Intake
Habits: Cigarettes
Coffee
Tea
Cola
Alcohol
Drugs
Sugar
Salt
Other_______
Average Daily Diet:
Morning _________________________________________________________________________
Afternoon ________________________________________________________________________
Evening __________________________________________________________________________
Please check any that apply to you currently
Poor appetite
Heavy appetite
Poor sleep
Heavy sleep
Insomnia
Fatigue
Tremors
Vertigo
Cold hands
Cold feet
Cold back
Cold abdomen
Fevers
Chills
Night sweats
Sweat easily
Cravings
Localized weakness
Poor coordination
Change in appetite
Sudden energy drop at ______(time)
Peculiar tastes/smells______________________
Strong thirst (cold/hot drinks) _________ Bleed or bruise easily (where)_________________
Family History
Please indicate if a close relative (parent, grandparent, sibling) has any of the following:
Condition
Relative
Condition
Relative
 Allergies/Hay fever
 Eczema/Psoriasis
 Anemia
 Food Intolerances
 Arthritis
 Heart Disease
 Asthma
 High Blood Pressure
 Autoimmune Disease
 Juvenile Arthritis
 Birth Defects
 Kidney Disease
 Bleeding Disorder
 Mental Illness
 Cancer
 Seizures
 Depression/Anxiety
 Stroke
 Diabetes
 Tuberculosis
 Other:
 Other:
 I don’t know the family medical history
SKIN AND HAIR
Rashes
Ulcerations
Hives
Itching
Eczema
Pimples
Dandruff
Changes in hair/skin texture
Loss of hair
Purpura
Other hair or skin problems_______________________
HEAD, EYES, EARS, NOSE AND THROAT
Dizziness
Concussions
Migraines
Glasses
Eye strain
Eye pain
Poor vision
Night blindness
Color blindness
Cataracts
Blurry vision
Earaches
Ringing in ears
Poor hearing
Nose bleeds
Sinus problems
Mucus
Dry throat
Dry mouth
Copious saliva
Teeth problems
Jaw clicks
Grinding teeth Facial pain
Gum problems Spots in eyes
Recurrent sore throats ____________/month
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

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Massage Intake - Patient Information Form Massage Intake - Patient Information Form Medical
Form 20100813 - Patient Information Form Form 20100813 - Patient Information Form Medical
Patient Information Form For Patients Under 18 Years Of Age Form Patient Information Form For Patients Under 18 Years Of Age Form Medical
Patient Information Form With Emergency Contact And Health Information Patient Information Form With Emergency Contact And Health Information Medical
Patient Information Form Patient Information Form Medical
Patient Information Form Patient Information Form Medical
Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care Medical
Patient Information Form Patient Information Form Medical
Patient Information Form Patient Information Form Medical
Patient Information Form Patient Information Form Medical

Related Categories

Parent category: Medical
Download
Go
Page of 4