New Patient Health History Intake Form

Health History Intake
Acupuncture is a holistic form of medicine, which means that we take the functioning of all body systems into account when assessing a patient. In order to give you the very best and most effective treatment, we must go beyond simply examining your most prominent symptoms by obtaining a comprehensive health history. Thank you for taking the time to provide this important health information.
Today's Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
What name do you prefer to be called?*
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
How did you hear about Nurturing Spirit Acupuncture?*
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Relationship*
Current Health Concerns and Health History
Please list the main health issues you would like to address in order of importance. Use as many or as few of the response fields as you need.
Health Issue #1*
When did it begin?*
What other treatments have you tried, if any?*
Health Issue #2
When did it begin?
What other treatments have you tried, if any?
Health Issue #3
When did it begin?
What other treatments have you tried, if any?
Health Issue #4
When did it begin?
What other treatments have you tried, if any?
Any other health issues you would like to address
How do these health issues affect your daily life?*
Please list and give the date(s) of any significant health events, e.g. major illnesses, hospitalizations, injuries, traumas, and/or surgeries:*
Please indicate any areas of discomfort, tension, or pain by using your mouse, trackpad, or touchscreen to draw on the image below. To draw directly on the image, make sure you have selected the pencil icon.
If you would prefer to describe areas of discomfort, tension, or pain in writing, or have more comments to add on this subject, please do so below.
Please list any prescriptions, over the counter medications, vitamins, herbs, and/or supplements you are currently taking or have taken in the last three months:*
Please list any implantable medical devices (e.g. pacemakers, medication pumps), surgical hardware, or prosthetic joints that are currently in your body.
Please list allergies or sensitivities to any medications, foods, substances, or environmental agents (dust, pollen, etc.):*
Have you ever been treated with acupuncture or East Asian medicine before?*

YesNo
If "Yes," please note any significant positive or negative effects from those treatments.
Lifestyle and Nutrition
Relationship Status

SinglePartneredMarriedDivorcedWidowedOther
Occupation*
Do you experience any type of occupational stress (physical, psychological, chemical)?*

YesNo
If "Yes," please describe:
Do you exercise regularly*

YesNo
If "Yes," please describe. If you are not exercising regularly but would like to be, please describe the factors limiting you.
Average hours of sleep per night:*
Average ounces of water per day:*
Number of caffeinated drinks (coffee, tea, soda) per week:*
Do you smoke?*

YesNo
If "Yes," how much?
Do you observe any dietary restrictions?*

YesNo
If "Yes," please describe.
Do you crave any particular flavor? Please select all that apply*

SaltySourBitterSweetPungent or spicyNo particular cravings
Please describe your average daily food intake.
Morning
Afternoon
Evening
Symptoms and Conditions

Please indicate which of these symptoms or conditions you are experiencing now, or have experienced in a significant way in the past.
ENERGY, SLEEP, TEMPERATURE, AND WEIGHT*
Other related symptom or condition and/or additional details:
MUSCULOSKELETAL*
Other musculoskeletal condition and/or additional details:
HEAD, EYES, EARS, NOSE, MOUTH, AND THROAT*
Other related symptom or condition and/or additional details:
IMMUNITY, INFECTION, AND INFLAMMATION*
Other immune, infectious, or inflammatory symptom or condition and/or additional details. If relevant, please add specific information on any of the conditions listed above (e.g. type of autoimmune disorder, specific parasites, dates of past significant infections, etc.):
RESPIRATORY*
Other respiratory symptom or condition and/or additional details:
CARDIOVASCULAR AND CIRCULATORY*
Other cardiovascular or circulatory symptom or condition and/or additional details:
GASTROINTESTINAL*
Other gastrointestinal symptom or condition and/or additional details:
URINARY*
Other urinary symptom or condition and/or additional details:
REPRODUCTIVE*
Other reproductive symptom or condition and/or additional details:
IF YOU MENSTRUATE:
Date of the start of your last period

MonthDayYear
Date
Number of days your period lasts
Number of days your whole cycle lasts
Overall, your menstrual flow is:
Age at first period
Age at menopause

Please indicate the number of each pregnancy-related event you have experienced. Please skip this section if it does not apply to you.

	Number
Pregnancies
Live Births
Premature Births
Miscarriages
Terminations

Please describe any past complications during pregnancies, deliveries, or post-partum:
Are you currently pregnant?

YesNo
If you are pregnant, how many weeks?
If you are pregnant, have you experienced any complications during this pregnancy?

YesNo
If "Yes," please describe the complications:
NEUROLOGICAL*
Other neurological symptom or condition and/or additional details:
PSYCHOLOGICAL AND EMOTIONAL*
Other psychological / emotional symptom or condition and/or additional details:
Family Medical History
Have any of your close blood relatives been diagnosed with any of the following health conditions?*
If applicable, please indicate what specific cancer, autoimmune, neurological and/or mental health diagnoses are present in your family history.
Is there any other information about yourself, your health history, or your health goals that you feel it is important to share?
Should be Empty:

Health History Intake

Emergency Contact Information

Current Health Concerns and Health History

Lifestyle and Nutrition

Symptoms and Conditions

Family Medical History