Medical Acupuncture
Personal Information
Name:
Date:
-
Month
-
Day
Year
Street Address:
City:
Zip Code:
Phone (Home):
(Cell):
Email
example@example.com
Emergency Contact:
Weight:
Height:
Age:
Date of Birth:
-
Month
-
Day
Year
Occupation:
Hours worked per week:
Family Physician:
How did you hear about us?
Reason for seeking this treatment?
Have you ever had acupuncture before?
Health History
Please indicate the conditions that apply ✓
Headaches(migraine)
Headaches(tension)
Headache(sinus)
Sinus Infections (frequent)
Allergies
Frequent Colds
Pregnant (currently)
Shortness of Breath
Chronic Chest Congestion
Chronic Cough
Frequent Urination
Painful Periods
Swollen Ankles
Night Pain
Sleep Disturbed by Pain
Rheumatoid Arthritis
Osteoarthritis
Back Pain
Neck Pain
Shoulder Pain
Constipation
Difficult Digestion
Diabetes
Abdominal Pain
Night Sweats
Smoker
High Blood Pressure
Low Blood Pressure
Dizziness
Heart Disease
Varicose Veins
Poor Circulation
Phlebitis
Sensitive Skin
Rashes (frequent)
Diarrhea
Hot Flashes
Easy Bruising
Smoke Packs per day?
Back
Next
Health History
PRIOR SURGERIES
YEAR
1.
2.
3.
4.
Please list ALL medications (prescription & nonprescription) that you take. ( Include herbals, vitamins, over-the-counter, street drugs, etc.)
MEDICATION
DOSAGE
1.
2.
3.
4.
5.
Do you take blood thinning products such as vitamin E, Plavix, Aspirin or Coumadin?
NO
YES
Do you have any food, environmental, or drug allergies?
NO
YES
ALLERGY
TYPE OF REACTION
1.
2.
Do you smoke?
NO
YES
TYPE OF SMOKING (pipe, cigar, cigarettes, marijuana, chew, etc.)
HOW MUCH/ HOW LONG
1.
2.
Do you drink alcohol?
NO
YES
Socially only
Daily
Beer/Wine
Hard Liquor
Occupation:
Hand Dominance:
RIGHT
LEFT
Please describe family health issue below: FAMILY HISTORY
LIVING/ DECEASED
REASON FOR DEATH
MOTHER
FATHER
SIBLING(S)
Patient Signature:
Date
-
Month
-
Day
Year
Submit
Should be Empty: