Acupuncture Intake Form

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Acupuncture Intake Form
Date: ___________________________
Last name:
Birth date:
Address:
First name:
Check preferred contact #:
Phone (home):
☐
City:
Phone (work):
☐
Province:
Phone (cell):
☐
Postal Code:
Referred by:
Would you like to receive clinic
newsletter/promotions?:
Occupation:
Email:
Yes
☐
No
☐
Reason for visit:
Have you had acupuncture before:
Yes ☐
No ☐
Family Physician name:
Family Physician phone:
Western medical diagnosis (if applicable):
Other medical treatment received:
Physiotherapy ☐ Naturopathy ☐ Chiropractic ☐ Massage ☐
Other ☐
Please list any prescription medication or over the counter drugs currently taking:
1.
2.
3.
4.
5.
6.
Please list herbal medicine and other supplements currently taking:
1.
2.
3.
4.
5.
6.
Please list any allergies (food, drug, environmental, etc.):
1.
2.
3.
4.
Please indicate any of the following conditions that apply to you or an
immediate family member:
Heart
conditions
Diabetes
Stroke
Low blood pressure
Kidney disorder
High blood
pressure
Neurological
condition
Cancer
Respiratory
conditions
HIV/AIDS
Sprain/strain/fracture
Osteoporosis
Headaches/migraines
Jaw pain
Arthritis
Dizziness/fainting
Contagious illness
Skin conditions
Digestive problems
Hemophiliac
Wear a pacemaker
Lung condition
Epilepsy
Possibility of
pregnancy
Upcoming surgeries
Deep vein thrombosis
Spinal or head injury
Hepatitis
Do you use the following? If so, how often?
Cigarettes ☐
Alcohol
☐
Drugs
☐
Coffee
☐
☐
Pop
Do you participate in the following activities? If so, how often?
Yoga ☐
Running ☐
Fitness class ☐
Gym ☐
Biking ☐
Swimming ☐
Walking ☐
Other ☐
In the space below, please describe areas of pain/concern:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Check the sensations/pain characteristics:
Sharp
☐
Severe ☐
Burning
Stabbing
☐
☐
Moving
Shooting
☐
☐
Tingling
Throbbing
☐
☐
What relieves the pain (ice, rest, activity, massage, heat…)?
What aggravates the pain (weather, heat, cold, rest, activity…)?
Dull
☐
Numbness ☐
Check each symptom that you currently have, leave it blank if not applicable:
Gan
____ Irritability/Impatience
____ Depression
____ Stress
____ Emotional eating
____ Unfulfilled desires
____ Visual problems/
floaters
____ Blurred vision
____ Poor night vision
____ Red/dry/itchy eyes
____ Headaches/migraines
____ Dizziness
____ Feeling lump in throat
____ Muscle twitching/
spasm
____ Neck/shoulder
tension
____ Brittle nails
____ Sighing
____Sensation of pain
under rib cage
____ PMS
____ Genital itch/pain/rash
Xin
____ Palpitations
____Chest pain/tightness
____ Insomnia/sleep
problems
____Restlessness/easily
agitated
____ Vivid dreams
____ Lack of joy
____Forgetfulness
____ Aversion to heat
____ Bitter taste in mouth
____ Tongue/mouth ulcers/
cankers
Shen
____ Frequent urination
____ Bladder infection
____ Lack of bladder
control
____ Wake to urinate
____ Feel cold easily
____ Cold hands/feet
____ Night sweats
____ Hot flushing
____ Low sex drive
____ High sex drive
____ Loss of head hair
____ Hearing problems
____ Crave salty food
___ Fearful
____ Poor long term
memory
____ Ankle swelling
____ Tinnitus
Fei
____ Dry cough
____ Cough with
phlegm
____ Nasal
discharge/drip
____ Sinus infection/
congestion
____Itchy/painful throat
____ Dry mouth/nose/
throat
____ Skin rashes/hives
____ Snoring
____ Greif/sadness
____ Shortness of breath
____ Allergies
____ Asthma
____ Weak immune
system
____ Alternate chills/
fever
Pi
____ Heaviness in head/
body
____ Fatigue after eating
____ Difficult getting up in
the morning
____ Water retention
____ Muscular weakness/
tiredness
____ Bruise easily
____ Unusual bleeding
(nose, stool)
____ Bad breath
____ Poor appetite
____Increased appetite
____ Crave sweets
____ Poor digestion
____ Nausea/vomiting
____ Bloating/gas
____ Hemorrhoids
____ Constipation
____ Loose stool
____ Alternate
constipation/ loose stool
____Abdominal pain
____ Intestinal pain/
cramping
____Heartburn
____ Over thinking
____ Overweight
____ Foggy mind
____ Yeast infection
____ Aversion to cold
____ Cold nose
____ Increased thirst
____ Prefer warm drinks
____ Prefer cold drinks
____ Sweat easily
On a scale of 1-10, how would you rate your daily energy level (10 being best):
______________________________________________________________________________
______________________________________________________________________________
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