Acupuncture Intake Form

Personal Information

Patient Name: 	

Age: 		Birth Date: 	/ 	/ 	

Gender: 	

Address: 				 City: 	State: 	Zip:  		 Telephone (Day): 				 Telephone (Night): 				 Telephone (Mobile): 				 Email Address: 			 Occupation:  				 Referral Source:  				 Who is your primary heath care provider/MD?  				
Emergency Contact:  	Phone: 	

Main Complaint

Please identify your major health concerns

1.    	

How long have you had this problem?  	

2.    	

How long have you had this problem?  	

3.    	

	How long have you had this problem?  	

	Have you been given a diagnosis for these problems?  	

	What other treatments have you tried and what were the outcomes?  	

Personal Medical History (Please include your childhood history)

Illnesses		
Surgeries		
Significant Trauma: (i.e. motor vehicle accidents, fractures, etc.)		
Do have a history of current or past infectious disease? Please describe		
Medicines (please list all medications, herbs, vitamins and over the counter drugs)		
Allergies/Sensitivities (Please list any foods, drugs, medications or environmental factors which you are sensitive or allergic to)		

General (please check all that apply)
	Poor Appetite		Weakness		Sudden Energy Drops	
	Hearing Loss		Fevers		Chills	
	Easy to Bleed or Bruise		Sweat Easily		Fatigue	
	Strong Thirst		Poor Sleep		Tremors	
	Puffiness or Swelling		Poor Balance		Weight Loss	
	Night Sweats		Cravings		Weight Gain	
	Changes in Appetite		Other:			

Skin & Hair
	Rashes		Itching		Dandruff	
	Skin Ulcers		Eczema		Hair Loss	
	Hives		Pimples		Recent Moles	

Head, Eyes, Ears, Nose, and Throat
	Dizziness		Toothache		Blurry Vision	
	Cataracts		Ear Ringing		Sinus Problems	
	Taste/Smell Problems		Headaches		Concussions	
	Eye Strain/Pain		Night Blindness		Poor Hearing	
	Nose Bleeds		Facial Pain		TMJ Pain	
	Migraines		Ear Aches		Spots in Front of Eyes	
	Recurrent Sore Throat		Lip or Tongue Sores		Floaters	

Cardiovascular

	High Blood Pressure		Low Blood Pressure		Irregular Heartbeat	
	Cold Hands or Feet		Blood Clots		Palpitations	
	Swelling of Hands		Swelling of Feet		Chest Pain	
	Phlebitis		Fainting		Lightheadedness	

Respiratory
	Cough		Bronchitis		Difficulty Breathing	
	Phlegm		Coughing Up Blood		Pneumonia	
	Asthma		Painful Breathing		Easily Winded	

Gastro‐Intestinal
	Nausea		Constipation		Diarrhea	
	Bad Breath		Ulcers		Abdominal Pain	
	Chronic Laxative Use		Vomiting		Intestinal Gas	
	Indigestion		Rectal Pain		Belching	
	Blood in Stools		Hemorrhoids			

Urology
	Painful Urination		Urgency to Urinate		Unable to Hold Urine	
	Decrease in Urine Flow		Frequent Urination		Blood in Urine	
	Cloudy Urine		Kidney Stones		Frequent Night Urination	
	Pain in Groin Area		Sexually Transmitted			
			Disease			

Neuro‐Psychological
	Seizures		Areas of Numbness		Concussion	
	Twitches		Lack of Coordination		Depression	
	Irritability		Loss of Balance		Stress	
	Poor Memory		Anxiety		Mood Swings	
	Tremors					

Gynecology
 		Age of Menses		Irregular Periods		Clots	
 		Duration of Menses		Painful Periods		PMS	
 		Date of Last Menses		Breast Lumps		Menopausal	
 		# of Pregnancies		Spotting		Yeast Infections	
 		# of Births		Vaginal Discharge		Fertility Problems	

Musculo‐Skeletal
Arthritis	Muscle Weakness	Muscle Cramping
Muscle Spasms	Scoliosis	Weak Joints

Pain with Weather
Changes

Pain with Activity	Pain After Waking