Acupuncture Intake Form

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Acupuncture Intake Form
Please complete this questionnaire carefully. The information you provide will assist me in creating a complete
health profile for you. All of your answers are absolutely confidential. If you have any questions, please ask.
Patient Information (Please Print)
Name: _____________________________________
Date of First Visit:____________________________
Date of Birth: _____________________ M / F
Occupation: ______________________________________
Address:________________________________________________________Postal Code: ______________
Phone: (H) ______________________ (W) _____________________ (Cell) _________________________
Email Address___________________________________ Preferred method of contact: �� Home
Cell
E-Mail
Family Doctor: _______________________________________________Phone________________________
Emergency Contact Name: _____________________________________Phone: _______________________
How did you hear of us?_____________________________________________________________________
Have you ever had Acupuncture before?
YES
NO
What is your primary reason(s) for treatment today?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Have you visited a medical doctor for this condition? YES
NO
If yes, did you receive a diagnosis? NO
YES: _________________________________________________
Are you currently receiving any other treatments for this condition?
YES
NO
If yes, please describe treatments and how effective they have been: _________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Please list any current medications (prescription and over the counter), vitamins, supplements, herbs
or homeopathic remedies that you are taking, including dosage if you know it
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
For females: Are you pregnant? NO Possibly YES How far along? __________
Do you have a contagious disease at this time? NO
YES: _____________________________________

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