Patient Intake Form MEDICAL HISTORY Date * MM DD YYYY Name * First Name Last Name Email * Phone (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * Time of Birth Place of Birth Referred by Age * Height * Weight * Marital Status Occupation Special Stress With whom do you live? Why are you coming in for acupuncture? (What is your chief complaint)? * Details (hot/cold; pain/ache; moving/localized; sharp/dull; etc.) * History Other Complaints Name/Address of Primary Care Physician Names of other health care providers (Acupuncturist, Chiropractors, Therapists, etc.) Surgeries Other Hospitalizations Injuries/Accidents Other Diseases Medications (taken in the last month, prescription and non- prescription drugs with date and dosage if possible) Known Allergies Symptoms Review Directions: Check any of the following problems that have bothered you in the last 6 months. Comment in the space provided after the checklist regarding symptoms frequency (e.g. daily, weekly), time of last occurrence, duration opportunity to discuss all problems with the doctor. Blood Previous history of Anemia Tendency to bruise or bleed Easily swollen lymph glands Head Headaches Dizziness Eyes Vision problems Double Vision Blurred Vision Ears Poor Hearing Earaches Discharge Ringing in ears Nose Poor sense of smell Colds Obstructions Mouth Pain Ulcers in mouth Bleeding gums Unusual dental problems Sore Tongue Respiratory Cough Thick Sputum Wheezing Bloody Sputum Night Sweats Pain with Breathing Shortness of Breath Abnormal Chest X-ray Heart Chest Pain or Pressure Ankle Swelling Heart Palpitations Exercise intolerance Thank you!
