Patient Intake Form
Acupuncture for Optimal Health / Sue McComb, LAc,, DiplAc (NCCAOM), LMT
Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Email address *
Your answer
Phone information
Preferred phone number regarding your appointment
Your answer
Occupation
Your answer
Birthdate
Your answer
Referred by:
Your answer
In case of emergency , contact & phone
Your answer
Have you ever received therapeutic massage or acupuncture?
Your answer
Reason for this visit *
Your answer
Describe any injuries or accidents in the past 2 years
Your answer
Describe any pain, discomfort or recurring illness you experience
Your answer
List vitamins, homeopathic remedies, and/or prescriptions you're currently taking
Your answer
List any surgeries and the approximate year
Your answer
Gender at birth
Your answer
Gender at present
Your answer
Are you currently under a doctor's care? For what conditions? *
Your answer
List the two most common emotions you experience
Your answer
Additional comments
Your answer
I have listed all of my known medical conditions and physical limitations, and I will inform my acupuncturist of any changes in my physical health. I understand that my acupuncturist neither diagnoses illness, disease, or any other medical physical, or mental disorder; nor performs any spinal manipulations. I am responsible for consulting a qualified physician for any physical ailment I might have. I understand that I may experience slight bruising, swelling or burns due to acupuncture, electro-acupuncture, cupping, gua sha and moxibustion. I release my acupunturist from all of these and similar issures that are common to this modality of treatment. *
Signature and date *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service