Elevate Acupuncture Intake Form
Translate Form
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
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
Conditions
Have you had acupuncture before?
Yes
No
What is the main concern you would like to focus on?
Area of Complaint
Left Side of Neck
Characters:
0
/255
Right Side of Neck
Characters:
0
/255
Left Side of Upper Back
Characters:
0
/255
Right Side of Upper Back
Characters:
0
/255
Left Side of Mid Back
Characters:
0
/255
Right Side of Mid 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
Right Leg
Characters:
0
/255
Left Hip
Characters:
0
/255
Right Hip
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
Headaches
Migraines
Characters:
0
/255
Headaches
Characters:
0
/255
Cluster
Characters:
0
/255
Rebound
Characters:
0
/255
Sinus
Characters:
0
/255
Chronic Daily Headache
Characters:
0
/255
Tension
Characters:
0
/255
Neurological
Tingling
Characters:
0
/255
Multiple Sclerosis
Characters:
0
/255
Brain Injury
Characters:
0
/255
Stabbing
Characters:
0
/255
Cerebral-vascular Accident
Characters:
0
/255
Cerebral Vascular Accident (Stroke)
Characters:
0
/255
Sciatic Pain
Characters:
0
/255
Loss of Sensation
Characters:
0
/255
Seizure Disorder
Characters:
0
/255
Stroke
Characters:
0
/255
Transient Ischemic Attacks (TIA)
Characters:
0
/255
Vertebral and Spinal Cord Injury
Characters:
0
/255
Epilepsy
Characters:
0
/255
Shingles
Characters:
0
/255
Cerebral Palsy
Characters:
0
/255
Huntington Disease
Characters:
0
/255
Dizziness
Characters:
0
/255
Parkinsons
Characters:
0
/255
Brain Disorder
Characters:
0
/255
Numbness
Characters:
0
/255
Burning
Characters:
0
/255
Herniated Disc
Characters:
0
/255
Chronic Pain Disorder
Characters:
0
/255
Emotions
Nervous
Depressed
Anxious
Easily angered
Easily irritated
Moody
Manic
Crying easily
Fearful
Grieving
Other __________________
Characters:
0
/255
Cardiovascular
Cardiovascular Conditions
Characters:
0
/255
Congenital Heart Defect
Characters:
0
/255
Varicose Veins
Characters:
0
/255
Heart Attack
Characters:
0
/255
Blood Pressure
Characters:
0
/255
Acute Coronary Syndrome
Characters:
0
/255
Coronary Artery Disease
Characters:
0
/255
Blood Clots
Characters:
0
/255
Phlebitis
Characters:
0
/255
Aneurysm
Characters:
0
/255
Hyperlipidemia
Characters:
0
/255
Lymphedema
Characters:
0
/255
Cardiovascular Accident
Characters:
0
/255
Angina
Characters:
0
/255
Pericarditis
Characters:
0
/255
Pacemaker
Characters:
0
/255
Atherosclerosis
Characters:
0
/255
Raynaud Disease
Characters:
0
/255
Cold Hands
Characters:
0
/255
Heart Disease
Characters:
0
/255
Cardiac Arrhythmia
Characters:
0
/255
Rheumatic Heart Disease
Characters:
0
/255
High Blood Pressure
Characters:
0
/255
Cold Feet
Characters:
0
/255
Chronic Ischemic Heart Disease
Characters:
0
/255
Valve Disorders
Characters:
0
/255
Low Blood Pressure
Characters:
0
/255
Chronic Venous Insufficiency
Characters:
0
/255
Myocardial infarction
Characters:
0
/255
Congestive Heart Failure
Characters:
0
/255
Reproductive
History of STD/STI
Characters:
0
/255
Date of last menstrual period
Menses lasts
1
2
3
4
5
6
7
8
9
10
Days
Days
How many days between first date of this cycle and last cycle
Characters:
0
/255
Color:
Pale red
Bright red
Dark
Brown
Consistency
Thick
Watery
Clotting
Yes
No
Cramps (Better with)
Heat
Exercise
Rest
Breast tenderness
Acne
Mood changes
Food cravings
Bearing down sensation
Low Back pain
Spotting between periods
Menopause
Hot flashes
Vaginal dryness
Libido
Low
High
Normal
Pregnancies: ____,______ (#, most recent year)
Characters:
0
/255
Miscarriages: ____,_______ (#, most recent date) || How far along were you? __________ weeks
Characters:
0
/255
Abortions: ____,_______ (#, most recent date)
Characters:
0
/255
Abortions:
Medical
Personal
Decline to state
Never
Characters:
0
/255
On this date ___________
Characters:
0
/255
What kind? ___________
Characters:
0
/255
I have been ‘trying’ for _____________ years/months
Characters:
0
/255
Rounds of attempted IUI ______ when? ________________
Characters:
0
/255
Rounds of attempted IVF ______ do you have embryos already frozen? ________ #? ________
Do you track your ovulation?
Yes
No
What day of your cycle do you ovulate on?
Characters:
0
/255
Any known fertility or OB/Gyn history of your mother or sisters?
Yes, findings__________
Characters:
0
/255
No
Characters:
0
/255
Using donor sperm
Characters:
0
/255
Menstrual Cycle Disorder
Characters:
0
/255
Ovarian Cysts/Tumors
Characters:
0
/255
Pelvic Inflammatory Disease
Characters:
0
/255
Premenstrual Syndrome
Characters:
0
/255
Pregnancy
Characters:
0
/255
Uterine Disorder
Characters:
0
/255
Gynaecological Conditions
Characters:
0
/255
Breast Disorder
Characters:
0
/255
Ectopic Pregnancy
Characters:
0
/255
Endometriosis
Characters:
0
/255
Menopause
Characters:
0
/255
Immune
Non-Hodgkin Lymphoma
Characters:
0
/255
Rheumatoid Arthritis
Characters:
0
/255
Anaphylaxis
Characters:
0
/255
Allergies
Characters:
0
/255
Lupus
Characters:
0
/255
Hodgkin Lymphoma
Characters:
0
/255
Infectious Mononucleosis
Characters:
0
/255
Cancer
Characters:
0
/255
Leukemia
Characters:
0
/255
Musculoskeletal
Hereditary/Congenital Deformity
Characters:
0
/255
Strain/Sprain
Characters:
0
/255
Joint Injury
Characters:
0
/255
Amyotrophic Lateral Sclerosis (ALS)
Characters:
0
/255
Osgood-Schlatter Disease
Characters:
0
/255
Osteoporosis
Characters:
0
/255
Muscular Dystrophy
Characters:
0
/255
Osteoarthritis
Characters:
0
/255
Ankylosing Spondylitis
Characters:
0
/255
Gout
Characters:
0
/255
Osteomalacia
Characters:
0
/255
Myasthenia Gravis
Characters:
0
/255
Tendonitis/Bursitis
Characters:
0
/255
Bone Disease
Characters:
0
/255
Paget Disease
Characters:
0
/255
Sinus Problems
Characters:
0
/255
Compartment Syndrome
Characters:
0
/255
Psoriatic Arthritis
Characters:
0
/255
Artificial Joints / Special Equipment
Characters:
0
/255
Dislocation
Characters:
0
/255
Scleroderma
Characters:
0
/255
Fibromyalgia
Characters:
0
/255
Fracture
Characters:
0
/255
Arthritis
Characters:
0
/255
Jaw Pain (TMJD)
Characters:
0
/255
Scoliosis
Characters:
0
/255
Gastrointestinal
Constipation
Characters:
0
/255
Digestive Conditions
Characters:
0
/255
Poor Appetite
Characters:
0
/255
Diarrhea
Characters:
0
/255
Stomach Disorder
Characters:
0
/255
Crohn's Disease
Characters:
0
/255
Diverticulitis
Characters:
0
/255
Ulcerative Colitis
Characters:
0
/255
Eating Disorder
Characters:
0
/255
Esophageal Disorder
Characters:
0
/255
Fecal Impaction
Characters:
0
/255
Intestinal Polyps
Characters:
0
/255
Celiac Disease
Characters:
0
/255
Irritable Bowel Syndrome
Characters:
0
/255
Blood
Hypercoagulability
Characters:
0
/255
Hepatitis
Characters:
0
/255
Polycythemia
Characters:
0
/255
Haemophilia
Characters:
0
/255
HIV
Characters:
0
/255
Thrombosis/Embolism
Characters:
0
/255
High Cholesterol
Characters:
0
/255
Anemia
Characters:
0
/255
Bleeding Disorder
Characters:
0
/255
HIV/AIDS
Characters:
0
/255
Skin
Acne
Characters:
0
/255
Athlete's Foot
Characters:
0
/255
Psoriasis
Characters:
0
/255
Allergic Dermatosis
Characters:
0
/255
Rash
Characters:
0
/255
Bruise Easily
Characters:
0
/255
Athletes Foot
Characters:
0
/255
Herpes
Characters:
0
/255
Hypersensitive Reaction
Characters:
0
/255
Rosacea
Characters:
0
/255
Chemical Burn
Characters:
0
/255
UV Burn
Characters:
0
/255
Hypersensitive Reactions
Characters:
0
/255
Melanoma
Characters:
0
/255
Melanoma/Carcinoma
Characters:
0
/255
Skin Conditions
Characters:
0
/255
Infectious Skin Conditions
Characters:
0
/255
Pigmentary Disorder
Characters:
0
/255
Skin Irritations
Characters:
0
/255
Plantar's Wart
Characters:
0
/255
Respiratory
Chronic Cough
Characters:
0
/255
Respiratory Conditions
Characters:
0
/255
Shortness of Breath
Characters:
0
/255
Asthma
Characters:
0
/255
Tuberculosis
Characters:
0
/255
Emphysema
Characters:
0
/255
Bronchitis
Characters:
0
/255
Respiratory Tract Infection
Characters:
0
/255
COPD
Characters:
0
/255
Cystic Fibrosis
Characters:
0
/255
Infectious Respiratory Conditions
Characters:
0
/255
Hearing
Conductive Hearing Loss
Characters:
0
/255
Meniere Disease
Characters:
0
/255
Motion Sickness
Characters:
0
/255
Tinnitus
Characters:
0
/255
Ear Problems
Characters:
0
/255
Vertigo
Characters:
0
/255
Hearing Loss
Characters:
0
/255
Kidney
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
Electrolyte Imbalance
Characters:
0
/255
Kidney Stones
Characters:
0
/255
Endocrine
Acute Pancreatitis
Characters:
0
/255
Diabetes
Characters:
0
/255
Hyperthyroidism
Characters:
0
/255
Hypothyroidism
Characters:
0
/255
Pituitary and Growth Disorder
Characters:
0
/255
Prostate Condition
Characters:
0
/255
Family History
Arthritis
Characters:
0
/255
Cardiovascular
Characters:
0
/255
Respiratory
Characters:
0
/255
Miscellaneous
Vision Problems
Characters:
0
/255
Vision Loss
Characters:
0
/255
Mental Health Issues
Characters:
0
/255
Surgical Pins or Wire
Characters:
0
/255
Insomnia
Characters:
0
/255
Other Medical Conditions
Characters:
0
/255
Other Diagnosed Diseases
Characters:
0
/255
Medications
Medication
Add Another Medication
Injuries
Injury
Add Another Injury
Surgeries
Surgery
Add Another Surgery
Review & Agree
HIPAA Signature Consent
You need to accept this before submitting
Intake Consent
(Review Required)
You need to review and accept this before submitting
Payment and Cancelation Policy
(Review Required)
You need to review and accept this before submitting
Signature
×
Submit Form
×