Acupuncture Intake Form Page 3
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6Do you have any of the following?
O
O
O
Pacemaker
Hemophilia
Latex allergy
O
O
O
Surgical replacements
Sensitive skin
Nut allergy
O
O
Implants
Fear of needles
O
Other allergy __________________________________________________________________
Is There Family History of:
O
O
O
Alcoholism
Depression
Mental illness
O
O
O
Allergies
Diabetes
Seizures
O
O
O
Asthma
Heart disease
Stroke
O
O
Bleeding disorders
High blood pressure
O
O
Cancer
Kidney disease
O
Other___________________________________________________________________________
How much do you consume per day of:
Water _______ Coffee _______ Tea _______ Soda _______ Alcohol ______ Cigarettes ______
□ �� w arm �� d rinks �� �� �� �� �� �� �� �� □ �� c old �� d rinks
□ �� r oom �� t emperature �� d rinks? ��
Generally, do you prefer
□ �� a lways �� t hirsty �� �� �� �� □ �� r arely �� t hirsty �� o r �� �� �� �� �� □ �� t hirsty �� f or �� s ips �� l ater �� i n �� t he �� d ay? �� ��
Do you find that you are
What are your typical eating habits?
O
O
O
Skip Meal(s)___________
Eat too Fast
Excess Hunger
O
O
O
Eat in a Rush
Cannot eat when
No Desire to Eat
Worried/Stressed
O
O
Eat When Not Hungry
Eat late at night
O
Craving specific food(s)___________________________________________________________
O
Other: ________________________________________________________________________
What are your typical sleeping habits?
O
O
O
Hours slept/night ______
Trouble staying asleep
Disturbing dreams
O
O
O
Fall asleep quickly
Deep sleeper
Wake at same time every
O
O
night ________
Trouble falling asleep
Light sleeper
O
O
Difficulty waking up
Frequent dreaming
O
Other __________________________________________________________________________
How would you describe your energy levels?
O
O
O
High
Normal
Hyperactive
O
O
O
Low
Lethargic
Changes from day to day
O
Other _________________________________________________________________________
Do you have aversion to any of the following?
O
O
O
Cold
Dampness
Loud Noises
O
O
O
Wind
Heat
Crowds
O
Other _________________________________________________________________________
What is your Average Body Temperature?
O
O
O
O
Hot
Cold Hands &
Hotter @ Night
5 Center Heat
Feet
O
O
O
Cold
Colder @ night
Hot Joints
O
Other _________________________________________________________________________
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