2022 Acupuncture Intake Form

Private Acupuncture Intake Forms

Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All of your answers will be held absolutely confidential. If you have any questions, please ask. If there is anything you wish to bring to our attention, which is not asked on the form, please note it in the "Comments" section. Thank you!
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:*
Please enter a valid phone number.
Work Phone Number:
Please enter a valid phone number.
Home Phone Number:
Please enter a valid phone number.
Email*
example@example.com
Date of Birth:*

MonthDayYear
Date
Anatomical Gender:*
Gender-identity:*
Preferred pronouns:
Height:*
Weight:*
Occupation: *
Marital Status:
Referred by:*
How did you hear about us?*

Social Media (Facebook, Instagram, etc)Google searchYelpNextdoorArlNow/Patch/etc.Other
Other (name of family/friend, doctor, physician, group, etc. Put N/A if not applicable)*
Emergency Contact Name:*
Emergency Contact Phone Number:*
Emergency Contact Relationship:*
Would you like to receive email notifications on promotional discounts/newsletter?*

YESNO
Have you been treated by acupuncture or Oriental medicine before?*

YesNoYes, at The Teal Center (different acupuncturist and/or over 3 years ago)
Main problem(s) you would like us to help you with:*
How long ago did this problem begin? Please be specific:*
To what extent does this problem interfere with your daily activities, such as work, sleep, and sex?
Have you been given a diagnosis for this problem?*

YesNoNot applicable (Explain below)
If so, what?*
What kinds of treatments have you tried?*
Past Medical History
Significant Illnesses (Please check all that apply):*

DiabetesCancerHepatitisHigh Blood PressureHeart DiseaseRheumatic FeverThyroid DiseaseSeizuresVenereal DiseaseOther (please specify below)None of the above
Other:
Significant surgeries and trauma (auto accidents, falls, etc.):
Allergies and sensitivities (drugs, chemicals, foods):*
Family Medical History (Select all that apply):*

DiabetesHigh Blood PressureHeart DiseaseCancerRheumatic FeverThyroid DiseaseSeizuresVenereal DiseaseOther (please specify below)None of the above
Other:
Medicines taken within the last two months (chemical, physical, psychological):*
Do you have a regular exercise program? If yes, please describe:*
Have you ever been on a restricted diet? If yes, what kind(s)?*
Please describe your average daily diet:
Morning:
Afternoon:
Evening:
How much water do you drink per day?*
Do you smoke? If yes, how much?
How much caffeinated coffee, tea, or cola do you drink per week?*
Please describe any use of drugs for non-medical purposes:
Please list any painful or distressed areas of the body:*
Please check if you have had (in the last three months):
FeversBleed or bruise easilyPeculiar tastes or smellsStrong thirst (hot or cold drinks?)CravingsSweat easilyPoor sleepingSudden energy drop (what time of day?)FatigueChange in appetiteChillsWeight lossNight sweatsWeight GainNone of the Above
Please describe any details for selections above:
Head, eyes, ears, nose, and throat:*

DizzinessGlassesPoor visionCataractsRinging in earsSinus problemsGrinding teethTeeth problemsAny other head or neck problems?ConcussionsEye strainNight blindnessBlurry visionPoor hearingNose bleedsFacial painJaw clicksMigrainesEye painColor blindnessEarachesSpots in front of eyesRecurrent sore throatsSores on lips or tongueHeadaches (where, when?)None of the Above
Please describe any details for selections above:
Cardiovascular:*

High blood pressureIrregular heartbeatCold hands and feetBlood clotsAny other heart or blood vessel problems?Low blood pressureSwelling of handsPhlebitisDifficulty in breathingChest painFaintingSwelling of feetNone of the Above
Please describe any details for selections above:
Respiratory:*

CoughBronchitisCoughing bloodDifficulty in breathing when lying downPneumoniaAsthmaPain with deep breathProduction of phlegm; what color?Any other lung problems?None of the Above
Please describe any details for selections above:
Gastrointestinal:*

NauseaConstipationBlack stoolsBad breathAbdominal pain or crampsVomitingGasBlood in stoolsRectal painChronic laxative useDiarrheaBelchingIndigestionHemorrhoidsPoor appetiteAny other problems with your stomach or intestines?None of the Above
Please describe any details for selections above:
Genito-Urinary:*

Pain upon urinationUrgency to urinateDecrease in urine flowBlood in urineImpotenceUnable to hold urineKidney stonesHow many times a day do you urinate?Sores on genitalsAny particular color to your urine?Do you wake up to urinate? How often?Any other problems with your genital or urinary system?None of the above
Please describe any details for selections above:
Musculoskeletal:*

Neck painBack painHand/wrist painMuscle painMuscle weaknessShoulder painKnee painFoot/ankle painsHip painAny other joint or bone problems?None of the Above
Please describe any details for selections above:

Reproductive and gynecologic:

	Number of:
Pregnancies
Live births
Premature births
Miscarriages
Abortions

Vaginal DischargeBreast lumpsMenopause ageIrregular PeriodsMenstrual PainMenstrual ClotsUnusual periods (heavy, light, etc)Spotting or pain between periodsNone of the above/not applicable
Date of last period (Write N/A if not applicable):
# of days periods lasts (Write N/A if not applicable):
Age of 1st menses (Write N/A if not applicable):
Date of last pap and Results (Write N/A if not applicable):
Changes in body/psyche prior to period (Write N/A if not applicable):
Do you practice birth control? What type and for how long (Write N/A if not applicable):
Is there a chance you are pregnant now?

YesNoUnknownNot applicable
Neuropsychological:*

SeizuresMigrainesAreas of numbnessConcussionsBad temperLack of coordinationDepressionMood disordersPsychotic disordersSubstance Use disordersEasily susceptible to stressTremorsTardive DyskinesiaLoss of balanceInsomniaPoor memoryAnxietyOtherNone of the above
Have you ever been treated for emotional problems?*

YesNo
Have you ever considered or attempted suicide?*

YesNo
Any other neurological or psychological problems?
Please describe any details for selections above:
Comments: Please tell us any other problems you would like to discuss.

The Teal Center for Therapeutic Bodywork, Ltd.

Acupuncture & Chinese Herbal Medicine Informed Consent

Please take the time to read this form, which will provide you with some basic information about acupuncture.

Important Things to Keep in Mind Regarding Acupuncture Treatment:
- Always feel free to communicate with your practitioner about what you are experiencing during the treatment or any questions you may have about the treatment.
- Clients experience a wide variety of sensations when receiving acupuncture treatment. You may not feel much, or you may feel a small, sharp sensation as the needle is inserted. Once the needles are in, it is common to feel a sense of general relaxation, tingling, movement, temperature change, or mild achiness at the site of a needle or elsewhere; these are all positive signs that your body is responding to treatment. If a needle ever continues to feel sharp past the moment of insertion, let your acupuncturist know so that the needle can be adjusted to a more comfortable position.
- If you experience dizziness, nausea, a cold sweat, shortness of breath, or faintness during treatment, please tell you acupuncturist immediately. These symptoms may occur and are generally caused by anxiety when receiving acupuncture for the first time.
- While the needles are in place, relax and breathe fully, but do not change your position or move suddenly, as you may experience some discomfort at the needle sites.
- Maintain good personal hygiene.
- You will be more comfortable during your treatment if you have eaten prior to the session but are not excessively full.
Acupuncture and Related Techniques:

I understand that I may be treated with one or more of the following techniques. I understand that not all techniques are indicated for every person or condition, and I am free to ask my practitioner for more information about techniques to be used in my treatment.
- Insertion of needles into the body at various depths and locations
- Application of heat to the skin using moxa (an herb) or a conventional heat lamp
- A massage technique called "gua sha." This treatment leaves redness on the skin that may last from 1-5 days. Slight bruising or tenderness may persist after treatment
- Cupping to promote circulation. Cups may produce a red/purple color on the area treated lasting for 1-5 days
- Electrical stimulation of the needles using an electro-acupuncture device
- The expression of a few drops of blood from an acupuncture point may be performed to improve circulation. A lancet is inserted into the skin and a few drops of blood are expressed
- Therapeutic herbal consultation: Herbal and nutritional supplements (which are derived from plant, animal, and mineral sources) that may be recommended are traditionally considered safe in the practice of Chinese Medicine. I understand that some herbs may be inappropriate during pregnancy. If I experience any gastro intestinal upset or allergic reactions to the herbs, I will inform my acupuncturist.
I understand that my acupuncturist uses only sterile, single-use, disposable needles and follows universally prescribed precautions such as clean needle technique and hand washing to prevent the transmission of infectious

I understand that in some cases acupuncture may result in certain side effects, including local bruising, slight bleeding, dizziness, fainting, minor burns resulting from the use of heat therapies, temporary pain or discomfort, and/or temporary aggravation of symptoms existing prior to treatment.

Patient Responsibilities I understand that it is my responsibility as a patient to inform my acupuncturist about all aspects of my health and, as treatment progresses, to inform my practitioner of changes that occur. If I experience any pain, discomfort, or possible adverse side effects, it is my responsibility to immediately notify my practitioner. I acknowledge that I am ultimately responsible for my own health and self-care. Making healthy lifestyle choices can substantially support my healing process and enhance the outcome of the acupuncture treatments I receive.

Confidentiality I understand that the confidentiality of my file and the information I share in the course of treatment will be honored and preserved. I acknowledge that my practitioner is ethically and legally required to report certain information pertaining to the abuse of minors and elders or serious threats of violence.

I understand that each individual responds uniquely to treatment and, for this reason, my practitioner cannot guarantee the outcome of treatment. Some individuals experience total or partial relief of their symptoms after the first few treatments. Others notice a steady, gradual improvement. Occasionally, some people notice that their symptoms seem to worsen before they improve. I agree to share my responses with my acupuncturist at each follow-up visit so that my treatment plan can be adjusted accordingly.

By signing this informed consent form, I acknowledge that I have read the information above carefully and that I consent to receive acupuncture treatment.
Name:*

First NameLast Name
Patient Signature:*

Clear
Date:*

MonthDayYear
Date
Parent/Guardian name (if patient is a minor):

First NameLast Name
Parent/Guardian Signature (if patient is a minor):

Clear
Date

MonthDayYear
Date

The Teal Center for Therapeutic Bodywork, Ltd.

Client Agreement
I, First Name* Last Name* , give permission for my Teal Center practitioner to take notes about me, including health history/medical and/or personal information I choose to disclose. I understand that this information will be kept strictly confidential.
I understand that, according to OSHA, massage and bodywork represent a MEDIUM RISK while Covid-19 exists. I acknowledge that social distancing during a bodywork session is not possible and I accept full responsibility for taking that risk.

I also understand:

1. That massage therapy and/or acupuncture
- is for the purpose of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow; and
- is not a substitute for medical examination or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have
2. That the massage therapists and/or acupuncturists
- do not diagnose illness, disease or any other physical or mental disorder;
- do not prescribe medical treatment or pharmaceuticals; and
- do not perform any spinal manipulations
3. I agree that any and all appointment times are reserved exclusively for me and that I am responsible to remember them and to pay for appointments that I miss, cancel, or reschedule with less than 24 hours notice.

If I need to reschedule due to illness or Covid exposure, I agree to contact the Teal Center as soon as possible. I authorize The Teal Center to charge my credit card on file for 50% of the full amount of any appointment missed, cancelled, or rescheduled with less than 24 hours notice.

I have stated all my known medical conditions and take it upon myself to keep the practitioner updated on my physical health.
Name:*

First NameLast Name
Signature:*

Clear
Date:*

MonthDayYear
Date

Policies
Please READ and INITIAL each of the following

Welcome! Thank you for choosing The Teal Center!
Appointments missed, cancelled or rescheduled with less than 24 hours notice charged 50% of the session fee. To avoid being charged for a missed appointment, we invite send a friend or family member in your place. Also, if we can fill appointments missed, cancelled or rescheduled with less than 24 hours notice the client will charged. It is your responsibility to remember your appointments. Confirmation emails are sent 48 hours prior to the scheduled appointment.*
The Teal Center and its practitioners abide by the ethical standards of practice by their respective certification boards (NCBTMB and NCCAOM). All shall refrain from any behavior that sexualizes or appears to sexualize the client/therapist relationship. If such behavior occurs at any time, therapists are to terminate the session; payment will be made in full by the client and Center reserves the right to prohibit the client from returning to The Teal Center.*
If you have a cold or other contagious illness, please call us before your appointment so we can check with your therapist to see if it is appropriate for you to in.*
In order to preserve a peaceful environment, we ask that you silence your cell while at The Teal Center.*
Tips are appreciated but never expected. If you wish to leave a gratuity,we ask that you do so in cash or by check made directly to your therapist. Gratuity is also made possible via the Venmo app for some therapists.*
This is important so we can reach you in case of any emergency or any necessary and unforeseen scheduling changes.*
Please enter a valid phone number.
The Teal Center does not submit insurance claims. We are happy to provide with medical receipts, any treatment notes and payment history for your records. We will communicate directly with your insurer at their request.*
Name:*

First NameLast Name
Signature:*

Clear
Date:*

MonthDayYear
Date
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Private Acupuncture Intake Forms

Policies