Ocean Wellness
Acupuncture Patient Intake Form
This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. Please fill it out as
completely as possible even if you do not feel certain questions pertain to your present condition. Thank you.
Personal Information
Name_______________________________________________________________Age_________ Date _____________
Home
Address________________________________________________________________________________________
City________________________________________________________ Postal Code____________
Home Phone________________________ Work Phone________________E-mail_________________________
Birthdate__________________ If under 18, person responsible for your account__________________________________
Emergency Contact: Name__________________________________________ Contact Phone:____________________
Whom should we thank for referring you to our office? _____________________________________________________
Have you had acupuncture therapy before? □ Yes
□ No
Did it help you? □ Yes
□ No
Please indicate if any of the following pertain to you: (marking “yes” does not make you ineligible for treatment,
however, it may restrict some of our treatment modalities):
□ Hepatitis
□ HIV
□ High Blood Pressure
□ Seizures □ Pacemaker □ Blood-Thinning Meds □ Pregnancy
Please indicate the use and frequency of the following:
Coffee ____________________ Soda pop ___________________________Water _______________________________
Alcohol______________________ Recreational drugs ________________________ Tobacco______________________
Please list any prescription or over-the-counter medications you are presently taking:
Medication
Reason
____________________________________________
_______________________________________________
____________________________________________
_______________________________________________
____________________________________________
_______________________________________________
____________________________________________
_______________________________________________
____________________________________________
_______________________________________________
Health History
What are the health problems for which you are seeking treatment? ___________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________
How long have you had this condition?
____________________________________________________________________
What other forms of treatment have you sought? ___________________________________________________________
___________________________________________________________________________________________________
What helps your condition? ___________________________________________________________________________
What aggravates your condition? ________________________________________________________________________
Please list any surgeries or major health incidents (accidents, etc.) in your life:____________________________________
__________________________________________________________________________________
PAIN PATIENTS, please indicate the areas of the body you experience your pain: _______________________________
___________________________________________________________________________________________________
How would you characterize your pain:
□ dull/achy □ sharp/stabbing □ burning □ tingling
□ numbness
□ electrical
What would you like to achieve with acupuncture treatment? _________________________________________________
♀For Women
Age of first period ____________ Date of last period ____________ Number of children (live births) _______________
Number of days between periods (your cycle) ___________________Number of days of flow_______________________
Color of flow:
□ pale/light red
□ red
□ bright red
□ dark red
□ dark red/brown □ clots
Amount of flow:
□ spotting
□ light
□ even throughout
□ heavy
Other symptoms related to menses:
□ Constipation
□ Decreased Appetite
□ Diarrhea
□ Insomnia
# of pads you use per day
Pain and cramping:
1st day ___
2ND day ___
3RD day ___
4th day ___
+days ___
□ No
□ Yes
□ before flow
□ during flow
□ after flow
□ Discharge
□ Swollen Breasts
□ PMS
□ Headache
□ Mood Swings
Have you ever been diagnosed with: □ fibroids □ fibrocystic breasts □ endometriosis
□ polycystic ovary syndrome
□ STD _________________________
□ mild
□ moderate
□ severe
□ Nausea
□ Increased Appetite
□ ovarian cysts
□ PID
Are you on any form of birth control? ____ If yes, which kind?______________________________