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