Welcome to our office.
New Acupuncture Patient Paperwork
Please complete this paperwork to the best of your ability. If you do not understand or need help answering the questions, please ask one of our staff and we will be happy to assist you. Any question that has a red asterisk MUST be answered before you can continue to the next section.
Cell/Home Phone Number
Work Phone Number
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Date of Birth
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Emergency Contact's Name
Emergency Contact's Phone Number
Emergency Contact Relation
We're So Glad You're Here!
We want more patients like you, so we want to know how you found us.
How Did You Hear About Our Office?
Metal Business Cards
Who can we thank for referring you to our office?
We love sending thank you cards to show our appreciation!
Your Acupuncture Experience
Knowing about your previous Acupuncture experience will help us help you more effectively.
Have you ever had Acupuncture before?
Since you've had Acupuncture before...
What was your past Acupuncture experience like?
Who performed your previous Acupuncture treatment?
What was the approximate date of your LAST Acupuncture treatment?
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No Experience, No Worries!
We understand that something new and different may make you a bit nervous. It's okay to feel that way! We will walk you through this entire process to make sure are you are comfortable and answer all of your questions.
Does anything make you nervous about receiving your first Acupuncture treatment today?
How can we help you?
We want to know more about your reason for seeing us today. The more you tell us about what you are experiencing, the better we can diagnose the cause of your concern.
What brings you into our office today (please select all that apply to you)
Low back pain
Mid back pain
Numbness and tingling in arms/hands/legs/feet
Approximately when did this health concern begin?
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Why is it important for you to seek treatment today?
Is your health concern getting better, worse, or staying the same since it started?
staying the same
I can't tell
Have you ever had anything like this before?
Does your health concern interfere with your (please select all that apply to you)
Bowel and bladder function
Have you seen other doctors or health care providers for this?
So we aren't the first health care providers you've seen for this health concern...
Understanding what you've tried in the past to alleviate your health concern will help us determine the best course of treatment for you.
What type of treatment did you receive?
Was it beneficial in alleviating your symptoms?
What does your outcome look like?
We want to make sure we have the same end goal as you do. Your goals will become our goals.
What is your end goal for care?
Follow the recommended treatment plan, return to my normal routine, and then call as needed.
Follow the recommended treatment plan, return to my normal routine, and then continue with preventative care.
I'm not sure which option is best for me. Please help me decide.
What story does your past health experiences tell us?
Knowing your past health history is helpful to better understand your overall health.
What health ailments have you had in the past (please select all that apply to you)
Congestive heart failure
Eye pain or difficulties
High blood pressure
Irregular menstrual cycles
Loss of balance
Loss of hearing
Loss of smell
Loss of taste
Loss of memory
Sinus infections (reoccurring)
Shortness of breath
Smoker (past and/or present)
Swelling of ankles
Have you injured yourself due to an accident?
Knowing about your past injuries is helpful to better understand your overall health.
Have you had any accidents, injuries, broken bones, or bad falls that injured your head or body?
We just need to know a little bit more about your past injury.
What was the result of your accident/injury?
Have you had any past surgeries?
Knowing about your past surgeries is helpful to better understand your overall health.
Have you had any surgeries?
That's going to leave a scar!
We just need to know a little bit more about your past surgery.
What was the purpose of your past surgery?
Certification Statement and Agreement
Please acknowledge the statement below by checking the appropriate box and signing below.
I certify that I am the patient or legal guardian of the patient listed above. I have read, understand, and certify that the included information above is true and to the best of my knowledge complete. I consent to the collection and use of the above information to Touch of Wellness Chiropractic. I authorize this office and its staff to examine and treat my condition as the doctor(s) see fit. I hereby authorize the doctor(s) to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that my health/accident insurance policies are an arrangement between my insurance carrier and myself; not between my insurance carrier and Touch of Wellness Chiropractic. Touch of Wellness Chiropractic has no obligation to pursue payment from my insurance company if a submitted claim is denied, and I fully understand that the payment of services will become my responsibility and cannot be negotiated. I also understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment plan. I understand that the doctor(s) at Touch of Wellness Chiropractic do not have an obligation to accept me as a patient, can terminate my ability to be seen at Touch of Wellness Chiropractic at any time they see fit, and release me from care if I am not following my recommended treatment plan. By selecting the 'yes' option and signing below, I acknowledge and agree to the above statement.
Yes, I agree to the above statement and I am ready to receive treatment from the doctors at Touch of Wellness Chiropractic.
No, I do not agree to the above statement and I will not receive treatment from the doctors at Touch of Wellness Chiropractic.
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