Welcome To Qiworks Community Acupuncture (Page 2 of 4) in pdf

Welcome To Qiworks Community Acupuncture Page 2

801-364-9272

Today’s Date_____________

**Have you had acupuncture before? Yes or No (circle one)

Name______________________________________________________ Nickname________________________

Address _______________________________________City/State/Zip___________________________________

Email:_____________________________________________________________ Gender __________________

Birth date __________________ Best Phone #:____________________________________________________

Emergency Contact Name/Phone__________________________ _____________________________________

Occupation _____________________ How did you find out about us? ___________________________________

Reason(s) for your visit, in order of importance to you:



______________________________________________________________________



______________________________________________________________________



______________________________________________________________________

When/how did your concern(s) occur, and have you received a diagnosis and/or any treatment(s)?

Check any that apply

(or may apply) to you:

Please list current medications:

Pregnancy

Hepatitis

HIV

Please list significant illnesses, accidents, and/or surgeries:

Bleeding Disorders

Blood Thinners

Allergies (not seasonal)

Do you have trouble sleeping? _________________________________

Do you have trouble digesting your food? _________________________

For office use only

Do you feel like you have enough energy to get through the day? ______________

What is your stress level? (circle one) Low, Medium, High, Variable

What else would you like to tell us?

RTP:

Welcome To Qiworks Community Acupuncture Page 2