Contact Us
Contact Us Today!
Click here
New Patient Intake Form
1. Patient Information
Name *
Date *
Address (City, State, Zip) *
Date of Birth *
Age
Gender (At Birth)
Marital Status
Primary Phone *
Secondary Phone
Email *
Occupation
Height
Weight
Emergency Contact (Name & Phone) *
Referred By
2. Reason for Visit Today
Chief Complaint / Reason for Visit *
Have You Had Acupuncture Before?
Chinese Herbal Medicine?
How Long Have You Had This Condition?
Is It Getting Worse?
Does It Bother Your:
What Seems To Be The Initial Cause?
What Seems To Make It Better?
What Seems To Make It Worse?
3. Physician & Therapies
Are you under the care of a physician now?
If yes, for what?
Who is your physician?
Physician's Phone
Other Concurrent Therapies
Family Medical History
4. Your Diet
Appetite:
Regular Intake:
Thirst for water: (glasses per day)
Average Daily Menu
Morning
Snack
Noon
Snack
Evening
Snack
Pharmaceuticals taken in last 2 months:
Vitamins/Supplements taken in last 2 months:
5. Your Lifestyle
Alcohol:
Tobacco/Nicotine:
Marijuana:
Other drugs:
Stress:
Occupational Hazards:
Exercise:
Exercise Type:
6. Your Past Medical History

Check any of the following conditions you currently have, or have had in the past.

If Surgery or Other, specify:
7. Review of Systems

Check all that apply.

General Symptoms
Head, Eyes, Ears, Nose, Throat
Respiratory
Color of phlegm:
Cardiovascular
Gastrointestinal
Bowel movements:
Frequency:
Color:
Texture/Form:
Other:
Musculoskeletal
Skin and Hair
Neuropsychological
Genito-urinary
Gynecology
Age menses began
Length of cycle (day 1 to day 1)
Duration of flow
Pregnant?
# Pregnancies
# Live Births
Premature births
Age at Menopause
Date of last PAP
Date last period began
Other
Signature
Patient Signature (Type Name) *
Date *