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Edgewater Acupuncture New Patient Intake
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Email
*
Your email
Date
MM
/
DD
/
YYYY
Patient Name (& Parent/Guardian if under 18)
Your answer
Address - Street, City, State & Zip Code
Your answer
Date Of Birth
MM
/
DD
/
YYYY
Age
Your answer
Job
Your answer
Cell #
Your answer
Emergency Name / Phone Number
Your answer
Primary Doctor Name / Phone Number
Your answer
Current Medications (Include over the counter, supplements, vitamins & herbs)
Your answer
How Did You Find Us?
Referral
Facebook
Google
Other:
I Acknowledge: Payment is due at time of service. No-shows and cancellations with less than 24 hours notice will be charged $30 for treatments, $40 for new patient intakes.
*
Print Name and Date
Your answer
What are your health goals? And why is this important to you?
Your answer
For what problems are you currently seeking treatment? Rate the severity of each on a scale of 1-10, 1 = not bad at all, 10= the worst imaginable
Your answer
What impact are your symptoms currently having on your life? What are they preventing you from doing? Why is this important to you?
Your answer
What methods have you tried in the past to remedy these problems and how did these work for you?
Your answer
What roadblocks or challenges are stopping you from getting where you want to go? Put a *** on the biggest one.
Your answer
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