4. Initial Medical History form

iowa acupuncture clinic

8230 Hickman Road, suite B

Clive, Iowa 50325

Cell/text 515-331-8948

PATIENT last NAME*

PATIENT first name, MI*

PATIENT Birthday*

This is necessary for identification of Patient

DATE of upcoming visit*

Patient Phone number*

Please enter a valid phone number.

Contact Email

example@example.com

Is this the initial form or update?

InitialUpdate

Medication / Supplement / Herbal Medicine List

Please complete the following chart by listing all of the prescription medications, dietary supplements and/or herbal medicines that you are currently taking. describe your current health concerns and your medical history. Please be as detailed as you can. Please Upload (see end of form) extra pages or your own documents

	Medication / Supplement / Herb	Dosage times/day	Dosage total mg/day	medical reason / health benefit	Start date	End date
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Surgeries & Medical Procedures History

Please use the following chart to list all surgeries, organ removal, cosmetic surgical procedures, or other invasive medical procedures (such as chemo-therapy, radiation, cataract surgery Please include bone breaks and lacerations if they required exten- sive medical care. DO NOT INCLUDE HOSPITAL STAYS DUE TO ILLNESS, you will list those in the next section.

	Surgical Procedure	dates performed	reasons for procedure	was it successful? what were the results?
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PERSONAL Medical, Illness & Hospital History.

(you may send a PDF of this history instead.

See bottom of form to upload files)

	name of illness, diagnosis or birth defect	dates	hospitalized? how long?	what was result? Is disease sill active?
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Allergies

List Any Allergies and resulting symptoms:

	Allergen	Symptoms
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Family Medical History

Please list your family medical history.

Add any grandparents, siblings and/or

children that have significant medical history.

	relation	name	alive or dead	age	health / disease history
Mother
Father
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Add any documents, lists, photos or records by uploading the files here:

If you would like to pause and continue later, choose CONTINUE LATER button below.

Otherwise, choose SEND FORM button to make sure we receive your daily intake form before your appointment on: {dateOf}

You will be able to give us any changes or additional information at the time of your visit.

If you have any questions or concerns, please contact our clinic at:

cell/text: 515-331-8948

Make sure to look for your reminder text and/or emails.

See you soon,

iowa acupuncture clinic