Acupuncture Intake Form

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.

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

If female, when was your last cycle?

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If female, have you ever had a miscarriage?

Yes

Are you currently using birth control?

Yes

How long have you being using birth control, and what type are you on?

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Any previous surgeries/hospital admissions (please provide date and reason for hospitalization)?

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Do you have any skin or mesh grafts, implants, plates, pins, or pacemakers?

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Have you been diagnosed or are you currently receiving any form of treatment for Cancer?

Yes

If yes, what was the type of cancer and the method of treatment?

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Please list any Allergies/Sensitivities you may have:

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Please list your primary health concerns/chief complaints:

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Of which of these concerns is the most important to you? How long has this been a concern?

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What do you think has caused this problem?

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Does this effect your daily activities?

It does not affect them

I have had to stop doing some of them

I have had to change how I do things

I am unable to perform most activities

Traditional Chinese Medicine - Please check any of the follow that pertain to you:

Acid regurgitation

Heartburn

Large appetite

Bad breath

Ulcer (previously diag.) abdominal pain

Mouth sores (cankers)

Excessive gas

Burning sensation after eating

Bleeding, swollen and or painful gums

Low appetite

Worry

Easily bruised

Sudden weight loss abrupt weight gain

Overthinking

Pensive

Gurgling noises in the stomach

Fatigue after eating

Palpitation

Anxiety

Restlessness

Mental confusion

Waking unrefreshed

Frequent dreams

Drink Coffee/Tea (# of cups/day)

Normal Colour

Profuse Dark yellow

Strong odour

Bladder I Infections

Clear Burning

Cloudy Reddish easily startled

Scant Urgent

Painful Frequent

Wake during the night

Irritable bowel

Diarrhea

Hemorrhoids

Constipation

Colitis

Abdominal cramps

Crohn’s Disease

Bowel movement’s per day

Excess phlegm

Frequent Cold & Flu

Preference for hot drinks

Preference for cold drinks

Low energy

High energy typically run hot typically run cold

Blood/Insect Borne and Sexually Transmitted Diseases:

Please list how often you smoke and/or use alcohol:

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