The Acupuncture Center
Patient Intake Form
Email address *
Full Name *
Address *
City, State, Zip *
Cell Phone *
Alternate Phone
Email Address *
Emergency Contact Name and Number
Date of Birth *
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Gender
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Marital Status
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Occupation
Employer
Referred By;
Main Issue You Would Like to Discuss;
When did this begin?
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Was there an accident?
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What makes it better/worse?
Describe your pain:
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Does this condition interfere with;
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Have you sought previous treatment?
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What was your diagnosis?
What was your treatment?
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Please check any significant illnesses;
Check if experienced in past 3 months;
Have You Recently Had;
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Please Explain Results of Above Tests
Check if You Have any of the Following
Exercise
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Work Activity
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Habits
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Head Injuries
Fractures or Dislocations
Surgeries
Medications
Allergies
Supplements
Gynecology and Pregnancy (Females)
Duration of Flow
Age of First Menses
Date of Last Menses
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/
DD
/
YYYY
Last Pap
# of Pregnancies
# of Births
# of Miscarriages
# of Premature Births
Difficult Births
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