Name_________________________________Date of Birth___/__/____Sex__Age___SSN____________
Address________________________________________City__________________State___Zip________
Phone_____________________(Home)_______________________(Office)____________________(Cell)
Occupation_________________________________________E-mail Address_______________________
Emergency Contact ___________________________________________Phone______________________
Personal Physician____________________________________________Phone______________________
Referred by___________________________________________Have you had Acupuncture before______
I desire Acupuncture and Herbal Health, LLC personnel to provide me with the health therapies that I have requested including Acupuncture, Chinese Herbs, Guasha, Qigong, Sooji, Sotai, Cupping, and/or
Moxabustion. I understand this therapy may cause bruising, minor bleeding, and/or redness. The duration of treatment varies from person to person depending on his/her constitution and specific illness.. I acknowledge that Chinese/Japanese medical terminology does not equate with Western Medical diagnosis.
I hereby certify that all information provided to you is true.
_______________________________________________________________ ______/_______/________
Patient’s signature (Parent or guardian if under 18) Date
Present complaint________________________________________________________________________
______________________________________________________________________________________
How long have you experienced this difficulty?
________________________________________________
Have you been given a diagnosis?_____ If so, please describe____________________________________
______________________________________________________________________________________
Are you taking medications for this complaint?___ If so, please list________________________________
______________________________________________________________________________________
Past Medical History (please include dates)
Illnesses: ______________________________________________________________________________
______________________________________________________________________________________
Surgeries: _____________________________________________________________________________
______________________________________________________________________________________
Significant Trauma (auto accidents, falls, etc.:_________________________________________________
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Average of typical blood pressure ___/___ Do you have a pace maker or anything unusual in your body?____
If so, please describe:_____________________________________________________________________
Do you have or have you ever had any infectious diseases?___ If so, please describe _________________
______________________________________________________________________________________
Medicines (vitamins, herbs, prescriptions, over-the-counter drugs, etc.) taken within the last 3 months: ___
______________________________________________________________________________________
______________________________________________________________________________________
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