New Patient Intake Form

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Creekside Acupuncture and Natural Medicine
New Patient Intake Form
Name:____________________________________ Age:______ Date of Birth:____________
Address:_______________________City:______________State:______Zip:_____________
Phone Numbers: Home______________Work______________Cell_________________
Email Address: ___________________________________________
Occupation:______________________________________________
Emergency Contact: Name________________________Phone_____________________
Primary Care Doctor:______________________________________________________
How did you hear about this clinic?___________________________________________
Reason for today’s visit:____________________________________________________
Yes, I have been treated by Acupuncture before. Date of last treatment:_______
Yes, I am currently under a Physician’s care for:_________________________
Name of Physician:_________________________Phone:____________________
Yes, I am currently taking prescription drugs. Please list below:
_____________________________________________________________________________________
_____________________________________________________________________________________
Yes, I am currently taking supplements and/or vitamins. Please list below:
_____________________________________________________________________________________
_____________________________________________________________________________________
Yes, I have an infectious disease. Please describe:________________________
Yes, I have allergies. Please indicate:
Foods – Describe_____________________________________________
Medications – Describe________________________________________
Bites/Stings – Describe________________________________________
Seasonal – Describe__________________________________________
Animals – Describe___________________________________________
Other – Describe_____________________________________________
Personal Health History (Please check if any of the following apply)
AIDS
Diabetes
Hepatitis
Alcoholism
Emphysema
High Blood Pressure
Asthma
Epilepsy
Multiple Sclerosis
Allergies
Endocrine Disorder
Thyroid Disease
Arteriosclerosis
Gout
Childhood Fevers
Birth Trauma (yours)
Heart Disease
Childhood Illnesses
Major Surgeries (please list all with approx. dates):______________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Significant Trauma (auto accidents, falls, etc. Please list with approx. date of injury):____________
__________________________________________________________________________________
__________________________________________________________________________________
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