Intake Form
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
/
/
Gender
Male
Female
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
Characters:
0
/255
General Health
Characters:
0
/255
Current Treatment
Characters:
0
/255
Past Treatment (from other practitioners)
Characters:
0
/255
Medications
Injuries
Surgeries
Additional Info
Insurance Info
Insurer's Name
Characters:
0
/255
Adjuster's Name
Characters:
0
/255
Policy Number
Characters:
0
/255
Office Address
Characters:
0
/255
Unit #
Characters:
0
/255
City
Characters:
0
/255
Country
Characters:
0
/255
Prov / State
Characters:
0
/255
Postal Code / Zip
Characters:
0
/255
Phone
Characters:
0
/255
Fax
Characters:
0
/255
Email Address
Characters:
0
/255
Claims / Benefit
Conditions
TMJ (Jaw)
Ear Pressure
Characters:
0
/255
Grinding
Characters:
0
/255
Jaw Pain
Characters:
0
/255
Ear Blockage
Characters:
0
/255
Clicking
Characters:
0
/255
Difficulty Opening Jaw
Characters:
0
/255
Locking
Characters:
0
/255
Difficulty Chewing
Characters:
0
/255
Clenching
Characters:
0
/255
Morning Stiffness
Characters:
0
/255
Ear Ringing
Characters:
0
/255
Ear Stuffiness
Characters:
0
/255
Male Health
Difficulty Experiencing Orgasm
Characters:
0
/255
PSA Test Results
Characters:
0
/255
Sperm Count Results
Characters:
0
/255
Urinary Stream Changes
Characters:
0
/255
Painful Urination
Characters:
0
/255
Difficulty Maintaining Erection
Characters:
0
/255
Nocturnal Urination
Characters:
0
/255
Difficulty Obtaining Erection
Characters:
0
/255
Family History of Prostate Disease
Characters:
0
/255
Painful Ejaculation
Characters:
0
/255
Family History of Prostate Cancer
Characters:
0
/255
History of STD
Characters:
0
/255
History of Back Injury
Characters:
0
/255
Energy
Does your energy fluctuate?
Characters:
0
/255
Is your energy constant?
Characters:
0
/255
When is your energy highest?
Characters:
0
/255
When is your energy lowest?
Characters:
0
/255
What is your energy level upon awakening?
Characters:
0
/255
How long do you sleep on average?
Characters:
0
/255
Do you struggle with insomnia?
Characters:
0
/255
Well Being
Exercise
Characters:
0
/255
Sports
Characters:
0
/255
Flexibility
Characters:
0
/255
Range of Motion
Characters:
0
/255
Drinking
Characters:
0
/255
Hobbies
Characters:
0
/255
Smoking
Characters:
0
/255
Interests
Characters:
0
/255
Caffeine
Characters:
0
/255
Mobility/Walking Aids
Characters:
0
/255
Female Health
First Period
Characters:
0
/255
Last Period
Characters:
0
/255
Number of Pregnancies
Characters:
0
/255
Number of Live Births
Characters:
0
/255
Last PAP test
Characters:
0
/255
Abnormal PAP test
Characters:
0
/255
Irregular Periods
Characters:
0
/255
Menstrual Cycle Length
Characters:
0
/255
Menstrual Period Length
Characters:
0
/255
Menstrual Cramping
Characters:
0
/255
Heavy Bleeding
Characters:
0
/255
Endometriosis
Characters:
0
/255
Infertility
Characters:
0
/255
Unwanted hair growth
Characters:
0
/255
Premenstrual Syndrome
Characters:
0
/255
Breast Cancer
Characters:
0
/255
Ovarian Cancer
Characters:
0
/255
Osteoporosis
Characters:
0
/255
Current Menopausal Concerns
Characters:
0
/255
Currently Pregnant
Characters:
0
/255
Birth Control Method
Characters:
0
/255
Implants
Characters:
0
/255
Fibroids
Characters:
0
/255
PCOS
Characters:
0
/255
Uterine Polyps
Characters:
0
/255
Spotting
Characters:
0
/255
Dark Blood
Characters:
0
/255
Clots
Characters:
0
/255
Brown Spotting
Characters:
0
/255
Pencil Like Stool
Characters:
0
/255
Heaviness in Pelvis
Characters:
0
/255
Urinary Incontinence
Characters:
0
/255
Pelvic Organ Prolapse
Characters:
0
/255
Pelvic Floor Injury
Characters:
0
/255
Scar Tissue
Characters:
0
/255
Pelvic Pain
Characters:
0
/255
Pain with Sex
Characters:
0
/255
Area of Complaint
Neck
Characters:
0
/255
Left Side of Neck
Characters:
0
/255
Right Side of Neck
Characters:
0
/255
Upper Back
Characters:
0
/255
Left Side of Upper Back
Characters:
0
/255
Right Side of Upper Back
Characters:
0
/255
Mid Back
Characters:
0
/255
Left Side of Mid Back
Characters:
0
/255
Right Side of Mid Back
Characters:
0
/255
Low Back
Characters:
0
/255
Left Side of Low Back
Characters:
0
/255
Right Side of Low Back
Characters:
0
/255
Chest
Characters:
0
/255
Abdomen
Characters:
0
/255
Left Arm
Characters:
0
/255
Right Arm
Characters:
0
/255
Left Shoulder
Characters:
0
/255
Right Shoulder
Characters:
0
/255
Left Elbow
Characters:
0
/255
Right Elbow
Characters:
0
/255
Left Wrist
Characters:
0
/255
Right Wrist
Characters:
0
/255
Left Hand
Characters:
0
/255
Right Hand
Characters:
0
/255
Left Leg
Characters:
0
/255
Left Thigh
Characters:
0
/255
Left Calf
Characters:
0
/255
Right Leg
Characters:
0
/255
Right Thigh
Characters:
0
/255
Right Calf
Characters:
0
/255
Left Gluteal
Characters:
0
/255
Right Gluteal
Characters:
0
/255
Left Hip
Characters:
0
/255
Right Hip
Characters:
0
/255
Left Groin
Characters:
0
/255
Right Groin
Characters:
0
/255
Left Knee
Characters:
0
/255
Right Knee
Characters:
0
/255
Left Ankle
Characters:
0
/255
Right Ankle
Characters:
0
/255
Left Foot
Characters:
0
/255
Right Foot
Characters:
0
/255
Sacrum
Characters:
0
/255
Tailbone (coccyx)
Characters:
0
/255
Brain Disorders
ADHD
Characters:
0
/255
Generalized Anxiety Disorder
Characters:
0
/255
Autism
Characters:
0
/255
Obsessive Compulsive Disorder
Characters:
0
/255
Asperger Syndrome
Characters:
0
/255
Obsessive Compulsive Personality Disorder
Characters:
0
/255
Acute Stress Disorder
Characters:
0
/255
Bipolar Disorder
Characters:
0
/255
Panic Disorder
Characters:
0
/255
Agoraphobia
Characters:
0
/255
Borderline Personality Disorder
Characters:
0
/255
PTSD
Characters:
0
/255
Anorexia Nervosa
Characters:
0
/255
Bulimia Nervosa
Characters:
0
/255
Schizophrenia
Characters:
0
/255
Antisocial Personality Disorder
Characters:
0
/255
Claustrophobia
Characters:
0
/255
Sleep Disorder
Characters:
0
/255
ADD
Characters:
0
/255
Depression
Characters:
0
/255
Social Anxiety Disorder
Characters:
0
/255
Headaches
Chronic Daily Headache
Characters:
0
/255
Migraines
Characters:
0
/255
Tension
Characters:
0
/255
Headaches
Characters:
0
/255
Cluster
Characters:
0
/255
Rebound
Characters:
0
/255
Sinus
Characters:
0
/255
Other Headaches
Characters:
0
/255
Neurological
Parkinsons
Characters:
0
/255
Numbness
Characters:
0
/255
Brain Disorder
Characters:
0
/255
Peripheral Neuropathy
Characters:
0
/255
Chiari Malformation
Characters:
0
/255
Loss of Sensation
Characters:
0
/255
Dizziness
Characters:
0
/255
Herniated Disc
Characters:
0
/255
Burning
Characters:
0
/255
Chronic Pain Disorder
Characters:
0
/255
Syringomyelia
Characters:
0
/255
Multiple Sclerosis
Characters:
0
/255
Tingling
Characters:
0
/255
Stroke
Characters:
0
/255
Brain Injury
Characters:
0
/255
Tethered Cord
Characters:
0
/255
Stabbing
Characters:
0
/255
Cerebral Vascular Accident (Stroke)
Characters:
0
/255
Cerebrospinal Fluid Leak
Characters:
0
/255
Epilepsy
Characters:
0
/255
Seizure Disorder
Characters:
0
/255
Dural Ectasia
Characters:
0
/255
Sciatic Pain
Characters:
0
/255
Cerebral-vascular Accident
Characters:
0
/255
Transient Ischemic Attacks (TIA)
Characters:
0
/255
Vertebral and Spinal Cord Injury
Characters:
0
/255
Cerebral Palsy
Characters:
0
/255
Huntington Disease
Characters:
0
/255
Bell's Palsy
Characters:
0
/255
Shingles
Characters:
0
/255
Other Neurological
Characters:
0
/255
Skin
Herpes
Characters:
0
/255
Pigmentary Disorder
Characters:
0
/255
Non-Surgical Scars
Characters:
0
/255
Plantar's Wart
Characters:
0
/255
Surgical Scars
Characters:
0
/255
Acne
Characters:
0
/255
Psoriasis
Characters:
0
/255
Athlete's Foot
Characters:
0
/255
Allergic Dermatosis
Characters:
0
/255
Rash
Characters:
0
/255
Athletes Foot
Characters:
0
/255
Bruise Easily
Characters:
0
/255
Rosacea
Characters:
0
/255
Infectious Skin Conditions
Characters:
0
/255
Chemical Burn
Characters:
0
/255
UV Burn
Characters:
0
/255
Hypersensitive Reaction
Characters:
0
/255
Hypersensitive Reactions
Characters:
0
/255
Eczema
Characters:
0
/255
Skin Conditions
Characters:
0
/255
Melanoma
Characters:
0
/255
Melanoma/Carcinoma
Characters:
0
/255
Skin Irritations
Characters:
0
/255
Allergic to Iodine
Characters:
0
/255
Combination Skin
Characters:
0
/255
Dry Skin
Characters:
0
/255
Oily Skin
Characters:
0
/255
Mature Skin
Characters:
0
/255
Sensitive Skin
Characters:
0
/255
Sun Damage
Characters:
0
/255
Using ALPHA Hydroxy Acids
Characters:
0
/255
Using RETIN A
Characters:
0
/255
Other Skin
Characters:
0
/255
Respiratory
COPD
Characters:
0
/255
Chronic Cough
Characters:
0
/255
Cystic Fibrosis
Characters:
0
/255
Shortness of Breath
Characters:
0
/255
Asthma
Characters:
0
/255
Emphysema
Characters:
0
/255
Bronchitis
Characters:
0
/255
Tuberculosis
Characters:
0
/255
Infectious Respiratory Conditions
Characters:
0
/255
Respiratory Tract Infection
Characters:
0
/255
Respiratory Conditions
Characters:
0
/255
Other Respiratory
Characters:
0
/255
Cardiovascular
Chronic Ischemic Heart Disease
Characters:
0
/255
Valve Disorders
Characters:
0
/255
Heart Attack
Characters:
0
/255
Chronic Venous Insufficiency
Characters:
0
/255
Phlebitis
Characters:
0
/255
Congenital Heart Defect
Characters:
0
/255
Myocardial infarction
Characters:
0
/255
Coronary Artery Disease
Characters:
0
/255
Cardiovascular Accident
Characters:
0
/255
Blood Pressure
Characters:
0
/255
Blood Clots
Characters:
0
/255
Acute Coronary Syndrome
Characters:
0
/255
Varicose Veins
Characters:
0
/255
Hyperlipidemia
Characters:
0
/255
Swelling
Characters:
0
/255
Pacemaker
Characters:
0
/255
Lymphedema
Characters:
0
/255
Aneurysm
Characters:
0
/255
Pericarditis
Characters:
0
/255
High Blood Pressure
Characters:
0
/255
Heart Disease
Characters:
0
/255
Postural Orthostatic Tachycardia Syndrome
Characters:
0
/255
Angina
Characters:
0
/255
Cold Hands
Characters:
0
/255
Raynaud Disease
Characters:
0
/255
Low Blood Pressure
Characters:
0
/255
Cardiovascular Conditions
Characters:
0
/255
Atherosclerosis
Characters:
0
/255
Cardiac Arrhythmia
Characters:
0
/255
Cold Feet
Characters:
0
/255
Rheumatic Heart Disease
Characters:
0
/255
Congestive Heart Failure
Characters:
0
/255
Other Cardiovascular
Characters:
0
/255
Musculoskeletal
Fibromyalgia
Characters:
0
/255
Scleroderma
Characters:
0
/255
Osteoporosis
Characters:
0
/255
Dislocation
Characters:
0
/255
Chronic Fatigue Syndrome
Characters:
0
/255
Scoliosis
Characters:
0
/255
Torticollis
Characters:
0
/255
Jaw Pain (TMJD)
Characters:
0
/255
Artificial Joints / Special Equipment
Characters:
0
/255
Carpal Tunnel Syndrome
Characters:
0
/255
Fracture
Characters:
0
/255
Spondylolisthesis
Characters:
0
/255
Strain/Sprain
Characters:
0
/255
Baker's Cyst
Characters:
0
/255
Degenerative Disk Disease
Characters:
0
/255
Hereditary/Congenital Deformity
Characters:
0
/255
Joint Injury
Characters:
0
/255
Ehlers-Danlos Syndrome
Characters:
0
/255
Amyotrophic Lateral Sclerosis (ALS)
Characters:
0
/255
Recti Diastasis
Characters:
0
/255
Osgood-Schlatter Disease
Characters:
0
/255
Osteoarthritis
Characters:
0
/255
Muscular Dystrophy
Characters:
0
/255
Osteomalacia
Characters:
0
/255
Myasthenia Gravis
Characters:
0
/255
Gout
Characters:
0
/255
Arthritis
Characters:
0
/255
Ankylosing Spondylitis
Characters:
0
/255
Plantar Fasciitis
Characters:
0
/255
Paget Disease
Characters:
0
/255
Tendonitis/Bursitis
Characters:
0
/255
Bone Disease
Characters:
0
/255
Dupuytren's Contracture
Characters:
0
/255
Sinus Problems
Characters:
0
/255
Psoriatic Arthritis
Characters:
0
/255
Whiplash
Characters:
0
/255
Temporomandibular Joint Dysfunction
Characters:
0
/255
Compartment Syndrome
Characters:
0
/255
Chronic Myofascial Pain Syndrome
Characters:
0
/255
Other Musculoskeletal
Characters:
0
/255
Gastrointestinal
Intestinal Polyps
Characters:
0
/255
Celiac Disease
Characters:
0
/255
Irritable Bowel Syndrome
Characters:
0
/255
Constipation
Characters:
0
/255
Poor Appetite
Characters:
0
/255
Diarrhea
Characters:
0
/255
Diverticulitis
Characters:
0
/255
Crohn's Disease
Characters:
0
/255
Stomach Disorder
Characters:
0
/255
Eating Disorder
Characters:
0
/255
Ulcerative Colitis
Characters:
0
/255
Esophageal Disorder
Characters:
0
/255
Fecal Impaction
Characters:
0
/255
Gastroparesis
Characters:
0
/255
Digestive Conditions
Characters:
0
/255
Other Gastrointestinal
Characters:
0
/255
Blood
Bleeding Disorder
Characters:
0
/255
HIV/AIDS
Characters:
0
/255
Hypercoagulability
Characters:
0
/255
Polycythemia
Characters:
0
/255
Thrombosis/Embolism
Characters:
0
/255
Hepatitis
Characters:
0
/255
HIV
Characters:
0
/255
Anemia
Characters:
0
/255
Haemophilia
Characters:
0
/255
High Cholesterol
Characters:
0
/255
Other Blood
Characters:
0
/255
Family History
Respiratory
Characters:
0
/255
Diabetes
Characters:
0
/255
Cancer
Characters:
0
/255
Arthritis
Characters:
0
/255
Cardiovascular
Characters:
0
/255
Kidney
Electrolyte Imbalance
Characters:
0
/255
Kidney Stones
Characters:
0
/255
Renal Cysts
Characters:
0
/255
Urinary Incontinence
Characters:
0
/255
Urinary Tract Infection
Characters:
0
/255
Bladder Disorder
Characters:
0
/255
Chronic Kidney Disease
Characters:
0
/255
Congenital Kidney Disease
Characters:
0
/255
Other Kidney
Characters:
0
/255
Reproductive
Endometriosis
Characters:
0
/255
Pregnancy
Characters:
0
/255
Menopause
Characters:
0
/255
Gynaecological Conditions
Characters:
0
/255
Prostatitis
Characters:
0
/255
Menstrual Cycle Disorder
Characters:
0
/255
Enlarged Prostate
Characters:
0
/255
Ovarian Cysts/Tumors
Characters:
0
/255
Pelvic Inflammatory Disease
Characters:
0
/255
Premenstrual Syndrome
Characters:
0
/255
Breast Disorder
Characters:
0
/255
Uterine Disorder
Characters:
0
/255
Ectopic Pregnancy
Characters:
0
/255
Other Reproductive
Characters:
0
/255
Immune
Infectious Mononucleosis
Characters:
0
/255
Leukemia
Characters:
0
/255
Allergies
Characters:
0
/255
Non-Hodgkin Lymphoma
Characters:
0
/255
Sjogren's Syndrome
Characters:
0
/255
Cancer
Characters:
0
/255
Rheumatoid Arthritis
Characters:
0
/255
Anaphylaxis
Characters:
0
/255
Lupus
Characters:
0
/255
Hodgkin Lymphoma
Characters:
0
/255
Other Immune
Characters:
0
/255
Endocrine
Prostate Condition
Characters:
0
/255
Adrenal Fatigue
Characters:
0
/255
Diabetes
Characters:
0
/255
Acute Pancreatitis
Characters:
0
/255
Temiskaming Diabetes Program
Characters:
0
/255
Hyperthyroidism
Characters:
0
/255
Blood Sugar Managed?
Characters:
0
/255
Hypothyroidism
Characters:
0
/255
Wound Healing Status?
Characters:
0
/255
Pituitary and Growth Disorder
Characters:
0
/255
Other Endocrine
Characters:
0
/255
Hearing
Conductive Hearing Loss
Characters:
0
/255
Ear Problems
Characters:
0
/255
Meniere Disease
Characters:
0
/255
Hearing Loss
Characters:
0
/255
Motion Sickness
Characters:
0
/255
Tinnitus
Characters:
0
/255
Vertigo
Characters:
0
/255
Other Hearing
Characters:
0
/255
Miscellaneous
Other Medical Conditions
Characters:
0
/255
Eating Habits
Breakfast
Characters:
0
/255
Lunch
Characters:
0
/255
Dinner
Characters:
0
/255
Snacks
Characters:
0
/255
Emotion / Mood
Anxiety
Characters:
0
/255
Other Emotions
Characters:
0
/255
Fear
Characters:
0
/255
PTSD
Characters:
0
/255
Sadness
Characters:
0
/255
Stress Response and Coping Strategies
Characters:
0
/255
Depression
Characters:
0
/255
Overall mood and energy level
Characters:
0
/255
Grief
Characters:
0
/255
Rate the stress in your life (1-10)
Characters:
0
/255
Physical Abuse History
Characters:
0
/255
Despair
Characters:
0
/255
Mental Abuse History
Characters:
0
/255
Negative Self-Talk
Characters:
0
/255
Anger
Characters:
0
/255
Review & Agree
Informed Consent for Acupuncture Treatment and Care
You need to accept this before submitting
Signature
×
Submit Form
×