The Acupuncture Center
Patient Intake Form
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Email address
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Your email
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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DD
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Gender
Female
Male
Prefer not to say
Other:
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Marital Status
Married
Partner
Single
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Occupation
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Employer
Your answer
Referred By;
Your answer
Main Issue You Would Like to Discuss;
Your answer
When did this begin?
MM
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DD
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YYYY
Was there an accident?
Option 1
Yes
No
Maybe
Other:
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What makes it better/worse?
Your answer
Describe your pain:
Sharp
Tingle
Dull
Throb
Burn
Other:
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Does this condition interfere with;
Work
Sleep
Exercise
Meals
Daily Routine
Other:
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Have you sought previous treatment?
Yes
No
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What was your diagnosis?
Your answer
What was your treatment?
Medication
Surgery
Physical Therapy
Chiropractic
Massage
Other:
Clear selection
Please check any significant illnesses;
Cancer
Hepatitis
HIV
Asthma
Seizures
Heart Condition
Pacemaker
TB
Diabetes
Herpes
Thyroid
Venereal
Addiction
Hypertension
Stroke
Mental
Other:
Check if experienced in past 3 months;
Poor Appetite
Fever
Fatigue
Tremors
Cravings
Headaches
Localized Weakness
Insomnia
Strong Thirst
Poor Balance
Chills
Sudden Energy Drop
Peculiar Tastes or smells
Bleeding
Weight Loss
Joint Pain
Hearing Loss
Sweat Easily
Change in Appetite
Night Sweats
Depression
Emotional changes
Bruising Easily
Rashes
Eczema
Recent Moles
Itching
Hair Loss
Change in Hair Texture
Skin Issues
Dandruff
HIves
Ulcers
Acne
Psoriasis
Dizziness
Tinnitis
Gum Issues
Night Blindness
Facial Pain
Color Blindness
Eye Pain
New Glasses
Sinus Problems
Headaches
Blurred Vision
Jaw Click
Earaches
Glaucoma
Poor Vision
Cataracts
Concussion
Poor Hearing
Migraine
Eye Strain
Teeth Grinding
Floaters
Nose Bleeds
Spots in Vision
Recurrent Sore Throat
Toothache
Lip Sores
Mouth Ulcers
Cough
Wheezing
Cough up Blood
Bronchitis
Phlegm
Asthma
Short of Breath
Winded easily
Pain with Breathing
Blood Clots
Phlebitis
Chest Pain
Fainting
Edema legs, ankles, feet
Cold Hands and Feet
Edema Hands
Irregular Heartbeat
Low Blood Pressure
Difficult Breathing
Nausea
Belching
Diarrhea
Indigestion
Bloating
Constipation
Hemorrhoids
Parasites
Blood in Stool
Black Stool
Bad Breath
Gas
Abdominal Pain
Vomiting
Gastric Ulcers
Painful Urination
Blood in Urine
Genital Sores
Urgent Urination
Impotence
Kidney Stones
Scanty Urination
Unable to Hold Urine
Discolored Urine
Frequent Urination
Frequent Night Urination
Pressure in Perinium
Stress
Disorientation
Areas of Numbness
Lack of Coordination
Poor Memory
Migraines
Concussion
Depression
Anxiety
Easily Angered
Mood Swings
Attempted Suicide
Attend Psychiatric treatment
Nervous Habits
Neck Pain
Scoliosis
Hip Pain
Recent Sprains
Back Pain
Shoulder Pain
Arthritis
Weak Joints
Joint Pain
Knee Pain
Muscle Weakness
Injuries
Muscle Spasms
Muscle Soreness
Foot/Ankle Pain
Hand/Wrist Pain
Other:
Have You Recently Had;
Physical Exam
Blood Work
Urine Test
Spinal Exam
MRI, CT, Scan
Pregnancy Test
X-Ray
Other:
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Please Explain Results of Above Tests
Your answer
Check if You Have any of the Following
Alcoholism
Anemia
Anorexia
Bronchitis
Cancer
Bulemia
Chicken Pox
Cholesterolemia
Diabetes
Goiter
Hemophilia
Kidney Disease
Liver Disease
Measles
Mononucleosis
MS
Osteoporosis
Osteopenia
Pacemaker
Prostatitis
Psychosis
Scarlet Fever
Stroke
Tumors, Growths
Typhoid Fever
Whooping Cough
Epilepsy
Polio
Other:
Exercise
None
Daily
Moderate
Heavy
Clear selection
Work Activity
Sitting
Standing
Light Labor
Heavy Labor
Other:
Clear selection
Habits
Smoking
Alcohol Use
Caffeine Use
High Stress Level
Stress and/or Sleep Aids
Other:
Clear selection
Head Injuries
Your answer
Fractures or Dislocations
Your answer
Surgeries
Your answer
Medications
Your answer
Allergies
Your answer
Supplements
Your answer
Gynecology and Pregnancy (Females)
Irregular Period
Clots
Light Flow
Heavy Flow
PMS
Painful Periods
Fertility Problems
Breast Lumps
PCOS
Breast Cysts
Vaginal Discharge
Vaginal Sores
Other:
Duration of Flow
Your answer
Age of First Menses
Your answer
Date of Last Menses
MM
/
DD
/
YYYY
Last Pap
Your answer
# of Pregnancies
Your answer
# of Births
Your answer
# of Miscarriages
Your answer
# of Premature Births
Your answer
Difficult Births
Your answer
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