Acupuncture
Acupuncture
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
M
F
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
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
Conditions
HT/SI (Fire)
Skin Rash
Characters:
0
/255
Cysts/Tumor
Characters:
0
/255
Hot Palms/Soles
Characters:
0
/255
Sore Throat
Characters:
0
/255
Dry Scalp
Characters:
0
/255
Insomnia/Sleep Problems
Characters:
0
/255
Thirst
Characters:
0
/255
Ear Infection
Characters:
0
/255
Itchy/Burning Skin
Characters:
0
/255
Vivid Dreams
Characters:
0
/255
Easily Startled
Characters:
0
/255
Lack of Joy in Life
Characters:
0
/255
Excess Joy
Characters:
0
/255
Lymph Swelling
Characters:
0
/255
Aversion to Heat
Characters:
0
/255
Facial Redness
Characters:
0
/255
Night Sweats
Characters:
0
/255
Bitter Taste in Mouth
Characters:
0
/255
Gum Problems
Characters:
0
/255
Nose Bleed
Characters:
0
/255
Restlessness/Agitation
Characters:
0
/255
Chest Pain
Characters:
0
/255
Heart Palpitations
Characters:
0
/255
Treatment Goals
Stress Relief
Characters:
0
/255
Support in Healing/Recovery
Characters:
0
/255
Health Advice for Healing
Characters:
0
/255
Improve Lifestyle
Characters:
0
/255
Improve Symptoms
Characters:
0
/255
Improve Well Being
Characters:
0
/255
Pain Relief
Characters:
0
/255
Rehabilitation
Characters:
0
/255
Other
Characters:
0
/255
LU/LI (Metal)
Grief/Sadness
Characters:
0
/255
Snoring
Characters:
0
/255
Low Resistance to Colds/Flu
Characters:
0
/255
Nasal Discharge
Characters:
0
/255
Post-Nasal Drip
Characters:
0
/255
Asthma/Allergies
Characters:
0
/255
Shortness of Breath
Characters:
0
/255
Bronchitis
Characters:
0
/255
Sinus Trouble
Characters:
0
/255
Cough with Sputum
Characters:
0
/255
Skin Rashes/Hives
Characters:
0
/255
Dry Cough
Characters:
0
/255
Dry Mouth/Throat/Nose
Characters:
0
/255
Sneezing
Characters:
0
/255
LIV/GB (Wood)
Fullness Below Ribs
Characters:
0
/255
Joints/Neck/Shoulder Pain
Characters:
0
/255
Teeth Clenching at Night
Characters:
0
/255
Gall Stones
Characters:
0
/255
Muscle Cramping/Twitching
Characters:
0
/255
Tension
Characters:
0
/255
Blurred Vision
Characters:
0
/255
Headaches/Migraines
Characters:
0
/255
Poor Circulation
Characters:
0
/255
Visual Problems
Characters:
0
/255
Depression/Stress
Characters:
0
/255
Dizziness
Characters:
0
/255
Herpes Simplex
Characters:
0
/255
Red/Dry/Itchy Eyes
Characters:
0
/255
Eczema
Characters:
0
/255
Indecisive
Characters:
0
/255
Ringing in Ears
Characters:
0
/255
Emotional Eater
Characters:
0
/255
Insomnia 11pm-3am
Characters:
0
/255
Shingles
Characters:
0
/255
Feeling of Lump in Throat
Characters:
0
/255
Intermittent Mild Fever
Characters:
0
/255
Shoulder/Neck Tension
Characters:
0
/255
Irritability/Anger
Characters:
0
/255
Soft/Brittle Nails
Characters:
0
/255
KID/UB (Water)
Decrease Bone Density
Characters:
0
/255
Loss of Hair
Characters:
0
/255
Weakness/Pain in Lower Back
Characters:
0
/255
Emotional Instability
Characters:
0
/255
Low Sex Drive
Characters:
0
/255
Excess Worry
Characters:
0
/255
Poor Memory
Characters:
0
/255
Fear
Characters:
0
/255
Rapid Weight Change
Characters:
0
/255
Bladder Problems
Characters:
0
/255
Feel Cold Easily
Characters:
0
/255
Tendency to Gain Weight
Characters:
0
/255
Brain Foggy
Characters:
0
/255
Hearing Problems
Characters:
0
/255
Thyroid Problems
Characters:
0
/255
Craving/Avoiding Salty Foods
Characters:
0
/255
Hot Flash/Night Sweating
Characters:
0
/255
Urinary Problems
Characters:
0
/255
Dark Under Eyes
Characters:
0
/255
Lack of Bladder Control
Characters:
0
/255
Weak Leg/Knees
Characters:
0
/255
Health Questions
Hearing Impairment
Characters:
0
/255
Heart Attack
Characters:
0
/255
Heart Condition
Characters:
0
/255
Pacemaker
Characters:
0
/255
Asthma
Characters:
0
/255
Past Heart Surgery
Characters:
0
/255
Concussion
Characters:
0
/255
Stroke
Characters:
0
/255
Congenital Heart Defect
Characters:
0
/255
Epilepsy
Characters:
0
/255
SP/ST (Earth)
Easily Bruising & Bleeding
Characters:
0
/255
Indigestion/Heartburn
Characters:
0
/255
Abdominal Pain
Characters:
0
/255
Edema (Swelling)
Characters:
0
/255
Insulin Sensitivity
Characters:
0
/255
Bad Breath
Characters:
0
/255
Fatigue/Worse After Eating
Characters:
0
/255
Muscles Feel Tired Often
Characters:
0
/255
Nausea/Vomiting
Characters:
0
/255
Constipation
Characters:
0
/255
Gas/Belching
Characters:
0
/255
Over-Thinking
Characters:
0
/255
Crave Sweets
Characters:
0
/255
Hard to Get Up In AM
Characters:
0
/255
Decreased/Increased Appetite
Characters:
0
/255
Heaviness Anywhere in Body
Characters:
0
/255
Diarrhea
Characters:
0
/255
Hemorrhoids
Characters:
0
/255
Difficulty Digesting Fats/Oils
Characters:
0
/255
Hypoglycemia
Characters:
0
/255
Infectious
Pneumonia
Characters:
0
/255
Strep
Characters:
0
/255
Epstein Barr
Characters:
0
/255
Lyme Disease
Characters:
0
/255
Energy
Do you struggle with insomnia?
Characters:
0
/255
Does your energy fluctuate?
Characters:
0
/255
How long do you sleep on average?
Characters:
0
/255
Is your energy constant?
Characters:
0
/255
Emotion / Memory
Alzheimer Disease
Characters:
0
/255
Anxiety Disorder
Characters:
0
/255
Mood Disorder
Characters:
0
/255
Stress
Characters:
0
/255
Substance Use Disorder
Characters:
0
/255
Female Health
Hysterectomy
Characters:
0
/255
Menopause
Characters:
0
/255
PMS
Characters:
0
/255
Severe Menstrual Pain
Characters:
0
/255
Infertility
Characters:
0
/255
Breast Cancer
Characters:
0
/255
Ovarian Cancer
Characters:
0
/255
Osteoporosis
Characters:
0
/255
Current Menopausal Concerns
Characters:
0
/255
Area of Complaint
Neck
Characters:
0
/255
Upper Back
Characters:
0
/255
Mid Back
Characters:
0
/255
Low Back
Characters:
0
/255
Abdomen
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
Right Leg
Characters:
0
/255
Left Hip
Characters:
0
/255
Right Hip
Characters:
0
/255
Left Foot
Characters:
0
/255
Right Foot
Characters:
0
/255
Sacrum
Characters:
0
/255
Headaches
Chronic Daily Headache
Characters:
0
/255
Cluster
Characters:
0
/255
Headaches
Characters:
0
/255
Migraines
Characters:
0
/255
Sinus
Characters:
0
/255
Tension
Characters:
0
/255
Endocrine
Hyperthyroidism
Characters:
0
/255
Hypothyroidism
Characters:
0
/255
Diabetes
Characters:
0
/255
Other Endocrine
Characters:
0
/255
Neurological
Numbness
Characters:
0
/255
Cerebral Palsy
Characters:
0
/255
Parkinsons
Characters:
0
/255
Chronic Pain Disorder
Characters:
0
/255
Sciatic Pain
Characters:
0
/255
Dizziness
Characters:
0
/255
Sleeping Disorders
Characters:
0
/255
Epilepsy
Characters:
0
/255
Stroke
Characters:
0
/255
Fatigue
Characters:
0
/255
Tingling
Characters:
0
/255
Fibromyalgia
Characters:
0
/255
Twitching of Face
Characters:
0
/255
Bell's Palsy
Characters:
0
/255
Herniated Disc
Characters:
0
/255
Multiple Sclerosis
Characters:
0
/255
Carpal Tunnel
Characters:
0
/255
Gastrointestinal
Acid Reflux
Characters:
0
/255
Intestinal Gas/Bloating
Characters:
0
/255
Celiac Disease
Characters:
0
/255
Irritable Bowel Syndrome
Characters:
0
/255
Constipation
Characters:
0
/255
Ulcerative Colitis
Characters:
0
/255
Crohn's Disease
Characters:
0
/255
Diarrhea
Characters:
0
/255
Digestive Conditions
Characters:
0
/255
Diverticulitis
Characters:
0
/255
Gastroparesis
Characters:
0
/255
Reproductive
Enlarged Prostate
Characters:
0
/255
Gynaecological Conditions
Characters:
0
/255
Menstrual Cycle Disorder
Characters:
0
/255
Ovarian Cysts/Tumors
Characters:
0
/255
Pelvic Inflammatory Disease
Characters:
0
/255
Endometriosis
Characters:
0
/255
Musculoskeletal
Spasms / Cramps
Characters:
0
/255
Gout
Characters:
0
/255
Spondylolisthesis
Characters:
0
/255
Joint Injury
Characters:
0
/255
Strain/Sprain
Characters:
0
/255
Osteoarthritis
Characters:
0
/255
Osteoporosis
Characters:
0
/255
Temporomandibular Joint Dysfunction
Characters:
0
/255
Arthritis
Characters:
0
/255
Plantar Fasciitis
Characters:
0
/255
Tendonitis/Bursitis
Characters:
0
/255
Carpal Tunnel Syndrome
Characters:
0
/255
Psoriatic Arthritis
Characters:
0
/255
Whiplash
Characters:
0
/255
Chronic Fatigue Syndrome
Characters:
0
/255
Sinus Problems
Characters:
0
/255
Degenerative Disk Disease
Characters:
0
/255
Fibromyalgia
Characters:
0
/255
Family History
Arthritis
Characters:
0
/255
Cancer
Characters:
0
/255
Cardiovascular
Characters:
0
/255
Diabetes
Characters:
0
/255
Respiratory
Characters:
0
/255
Allergy
Environmental
Characters:
0
/255
Food
Characters:
0
/255
Latex
Characters:
0
/255
Medical
Characters:
0
/255
Emotion / Mood
Anger
Characters:
0
/255
Negative Self-Talk
Characters:
0
/255
Anxiety
Characters:
0
/255
Other Emotions
Characters:
0
/255
Confusion
Characters:
0
/255
Overall mood and energy level
Characters:
0
/255
Depression
Characters:
0
/255
Physical Abuse History
Characters:
0
/255
Despair
Characters:
0
/255
PTSD
Characters:
0
/255
Fear
Characters:
0
/255
Rate the stress in your life (1-10)
Characters:
0
/255
Grief
Characters:
0
/255
Sadness
Characters:
0
/255
Mental Abuse History
Characters:
0
/255
Stress Response and Coping Strategies
Characters:
0
/255
Review & Agree
Consent to Treat
You need to accept this before submitting
Signature
×
Submit Form
×