Acupuncture Intake Form Page 2
ADVERTISEMENT
1
2
3
4
5
6If you are seeking treatment for a painful condition, please describe the pain and shade in
areas of pain on the diagram below
Pain Condition #1
Degree of pain (please circle 1=low, 10=high)
1 2 3 4 5 6 7 8 9 10
Nature of the Pain
O Constant
O Comes and goes
O Fixed
O Moves
O One side
O Both sides
O Sharp
O Dull
O Burning
O Aching
O Spastic
O Numb
Does the pain get better, or worse with?
O Heat
better worse
O Cold
better worse
O Motion
better worse
O Rest
better worse
O Pressure better worse
O Better in AM or PM?
Pain Condition #2
Degree of pain (please circle 1=low, 10=high)
1 2 3 4 5 6 7 8 9 10
Nature of the Pain
O Constant
O Comes and goes
O Fixed
O Moves
O One side
O Both sides
O Sharp
O Dull
O Burning
O Aching
O Spastic
O Numb
Does the pain get better, or worse with?
O Heat
better worse
O Cold
better worse
O Motion
better worse
O Rest
better worse
O Pressure better worse
O Better in AM or PM
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business