Acupuncture Intake Form

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Main Complaint

Surgeries/Significant Trauma

MedicationsPlease attach additional Information if necessary

Vitamins/Supplements/Herbs

DietYesNoVegetarian

Meals per Day

CaffeineDrinks/Day

AlcoholDrinks/Week

ExcerciseDays/Week

Length of Workout

Type of Activity

Main Complaints

How long has it been since you first noticed any symptoms?

How does this problem affect your daily activities?

What kinds of treatment or therapy have you tried?

Have you ever tried acupuncture?

Personal History

Please check any conditions or symptoms you have now

Family Medical History

Please check any condition that applies to your immediate family and select the family member(s)

Other

Symptoms

Please check if you have had any of these symptoms listed in the last three months.

Do you Wake to Urinate?YesNo

No. of Pregnanices

No. of Births

No. of Miscarriages

No. of Premature Births

No. of Abortions

Age of First Menses

Date of Last Menses

Date of last PAP/Pelvic

Are You Pregnant?YesNo

Do you Practice Birth Control?YesNo

Have you ever been treated for emotional problems?YesNo

Do you have a spiritual life?YesNo

Have you ever considered or attempted suicide?YesNo

Have you ever been treated for substance abuse?YesNo

Any other Neurological or Psychological conditions?YesNo

Indicate on the scale of 0-10 your satisfaction in family relationshipsSatisfied (10) and Distressed (0)

Indicate on the scale of 0-10 your satisfaction in intimate relationshipsSatisfied (10) and Distressed (0)

Indicate on the scale of 0-10 your satisfaction in working relationshipsSatisfied (10) and Distressed (0)