Acupuncture Intake Form
Required Field
Please note that Chinese Medicine views the body as an intricate relationship between organs and systems. In order to fully understand your condition, it is important that you take the time to fill out this form.
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
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Contact Info
Mobile Phone
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Source of Referral
Address
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Australia
Canada
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Province / State
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Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Insurance
I have insurance
Insurer
Alberta Blue Cross
Canada Life
Chambers of Commerce Group Insurance
ClaimSecure
Co-Operators
Desjardins Insurance
Empire Life
Empire Life
Equitable Life of Canada
Green Shield Canada
GroupHEALTH
GroupSource
Industrial Alliance
Johnson Group
Johnson Inc.
Johnston Group Inc.
Manion
Manulife Financial
Maximum Benefit
Maximum Benefit
Medavie Blue Cross
National Blue Cross
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Sirius Benefit
SSQ Financial Group
Sun Life Financial
TELUS AdjudiCare
The Co-Operators
Policy Name
Policy / Group / Plan #
Member ID / Certificate #
Policy Holder
I'm not the policy holder.
First Name
Last Name
Relationship To Patient
Child
Parent
Spouse
Common Law Spouse
Other
Date of Birth
Address
City
Prov / State
Postal / Zip Code
Phone Number
Conditions
Information and Medical History
Reason for today's visit (primary complaint):
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History and duration of primary complaint
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Have you seen your family Dr. or any other practitioners regarding this complaint?
Yes
No
If yes, how long ago?
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Do you have any skin or mesh grafts, implants, plates, pins, or pacemakers?
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Traditional Chinese Medicine - In each category please check all symptoms that pertain to you and add comments as needed:
Pain Inquiry:
Where are you currently experiencing pain? Provide short answer and select symptoms below that best describe the pain.
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Chronic/constant
Episodic
Neural pain
Burning
Moving
Fixed in one location
Radiates to another area
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Spasm
Stabbing pain
Dull ache
Pounding/Throbbing
Better with cold/ice
Better with pressure
Better with heat
Better with activity
Better with rest
Additional comments?
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On a scale of 0 to 10 (0= no pain 10 = extreme pain) please indicate your pain level today
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General
Frequent episodes of colds & flus?
Easy bruising?
Do you have any allergies/sensitivities? Please describe.
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Energy Level
Adequate
Low/Feel fatigued all the time
High
I run on nervous energy
Energy drops after eating
Energy is low upon waking but improves as day goes on
Energy drops as day goes on
Daytime Somnolence
Sleep
Wakes feeling unrested
Sleep soundly and wakes rested
Difficulty falling asleep
Difficulty staying asleep
Dream disturbed sleep
Frequent nightmares
Walk and/or talks in sleep
Sleep Apnea
Nervous System
Dizzyness
Vertigo
Tremors
Seizures
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Balance Issues
Restless Legs
Palpitations
Anxiety
Easily overwhelmed
Easily agitated
Brain fog
Migraine headache (indicate location of pain)
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Headaches (other than migraine type). Please indicate location.
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Eyes, Ears, Nose and Throat
Frontal Headache
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Red and/or blood-shot eyes
Yellow sclera
Blurred vision
Double vision
Floaters
Dry eyes
Itchy eyes
Watery eyes
Discharge or crust on eyelids
Swelling and/or redness of eyelids
Ear congestion
Ear Ache
Ear discharge
Tinnitus/Ringing in the ear - low pitch
Tinnitus/ringing in the ear - high pitch
Throat spasm
Throat tension
Difficulty swallowing
Constant throat clearing
Sore throat
Dry nasal passages
Dry throat
Sinus congestion
Chronic sinus drip
Nasal Discharge
Constant
Clear and copious
Yellow and thick
Nose bleeds
TMJ
Jaw pain
Bell's Palsy
Trigeminal Neuralgia
Lung
Cough, dry
Cough, productive, easy to expectorate
Cough, productive, difficult to expectorate
Shortness of Breath
Alternating fevers & chills
Sneezing
Sore throat
Difficulty breathing
Dry skin
Grief
Metabolism/Body Temperature
Hands and feet cold (but not torso)
Cold feet
Cold hands
Always cold (whole body)
Always Hot
Perspires excessively with minimal activity
Lack of perspiration
Night Sweats
Hands and feet sweat excessivley
Afternoon Flush: warmer later in the afternoon/evening
Palms, soles and chest warm/hot
Temperature constantly alternates between hot and cold
Hot flashes
Numbness and/or tingling in extremities
Edema (location)
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Digestion and Elimination
Acid regurgitation
Heartburn
Nausea
Abdominal Bloating
Excessive flatulence/gas
Borborygmus/ Abdominal gurgling
Appetite
Large
Ravenous
Poor
Not hungry in the morning
Bad breath
Dry mouth
Mouth sores (cankers)
Burning sensation after eating
Bleeding, swollen and or painful gums
Sudden change in weight: either gain or loss
Fatigue after eating
Diarrhea
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Constipation
Bowel movement frequency (x/day)
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Hypochondrial Pain
Chest pain
Hemmorhoids
Abdominal Cramps
Abdominal pain
Heart
Palpitations
Angina/Chest pain
Restlessness
Mental confusion
Sadness/depression
Liver & Gallbladder Function:
Anger
Easily Irritability
Frustration
Depression
Hypochondrial pain
Ribcage tension
Neck tension
Muscle spasms
Limited Range of Motion (neck)
Limited Range of Motion (shoulder – Left or right)
Headache at the top of the head
Bitter taste in mouth
Gallstones (past or current)
Alternating diarrhea plus constipation
Skin rashes (location)
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Urination:
Clear
Cloudy
Urine is pale
Urine is dark yellow
Urine is red
Strong odour
Burning with urination
Pain with urination
Urinary retention
Scant Urgent
Frequent
Wake during the night
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Recurrent urinary tract infections
Women's Health
Do you have your menses today?
yes
No
Menses:
Regular
Irregular
No menstrual flow - amenorrhea
Menstrual pain (please describe)
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Menstrual flow is
light
heavy
has large clots
has small clots
erratic
Flooding and trickling
Hotflashes
Tender breasts
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PMS
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Menopause
Postmenopause
Men's Health:
Enlarged Prostate
Prostatitis
Erectile Dysfunction
Medical History: please select all current and preexisting conditions
Colitis
Cancer (please specify type)
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GERD
Gastric ulcer
Duodenal ulcer
Bleeding Disorder
Epilepsy
COPD
Heart Disease
Hypertension
Asthma
Autoimmune Disorder
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Diabetes
Thyroid Disorder
IBS
Crohn's disease
HIV/Aids
Encephalitis
Herpes
Hepatitis B
Hepatitis C
Tuberculosis
(TB) Pelvic Inflammatory Disease
Other (please specify)
Lifestyle & Dietary Profile
How much water do you drink in a day?
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Food and drink temperature preferance
Hot
Cold
Room temperature
Food flavor preferences
sweet
spicy
greasy
salty
bitter
pungent
Do you drink coffee/tea/ soft drinks? if yes, how much per day?
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Do you smoke? If so, how much/how often
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Do you drink alcohol? if yes, how much in a week?
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Please describe level of physical activity
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What are the major sources of stress in your life?
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Medications
Medication
Add Another Medication
Injuries
Injury
Add Another Injury
Surgeries
Surgery
Add Another Surgery
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