Confidential Patient Intake Form (Accupuncture)
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1
2Confidential Patient Intake Form
Name:________________________________________
Is this your first acupuncture experience? Yes No
Phone Number:_________________________________
How did you hear about us?
Email:________________________________________
⎕ Website
⎕ Word of Mouth
⎕ Newspaper
⎕ Referral
⎕ Walk/Drive By
⎕ Online Ad
Address:______________________________________
⎕ Other:_______________________________________
Personal Health Number:_________________________
Birth Date & Year:______________________________
**If patient is under 16 years of age**
Occupation:____________________________________
Parent/Guardian:________________________________
Family Physician:_______________________________
Signature:_____________________________________
Emergency Contact:_____________________________
Phone Number:_________________________________
Relationship:________________________________
Witness:______________________________________
Phone Number:______________________________
Main Complaints
Health History
Please list your main health complaints & concerns in order
Please indicate with P (past), C (current), or F (family) if any
of importance.
conditions apply.
1. _________________________________
__Cancer
__Bleeding Disorder
type?___________
__Anemia
MILD 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 SEVERE
__ Contagious Illness
__Lyme Disease
How Long:____________________________________
__Diabetes
__Chronic Pain
Other Treatments:_______________________________
__Heart Disease
__Blood Bourne Disease
What makes it better:___________________________
__Pacemaker
__Substance Abuse
__Osteoporosis
__Fibromyalgia
What makes it worse:___________________________
__Seizure Disorder
__Skin condition
__Stroke/TIA
type?________________
2. _________________________________
__Thyroid Condition
__Autoimmune Disease
MILD 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 SEVERE
Hyper / Hypo
type?________________
How Long:____________________________________
Medications (include herbs & supplements)
Other Treatments:______________________________
_____________________________________________
What makes it better:___________________________
_____________________________________________
What makes it worse:___________________________
_____________________________________________
_____________________________________________
3. _________________________________
_____________________________________________
MILD 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 SEVERE
Injuries/Surgeries (note when & where on body)
How Long:____________________________________
_____________________________________________
Other Treatments:_______________________________
_____________________________________________
What makes it better:____________________________
_____________________________________________
What makes it worse:____________________________
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