Elevate Acupuncture Intake Form
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Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
Male
Female
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
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
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
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Right Side of Neck
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Left Side of Upper Back
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Right Side of Upper Back
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Left Side of Mid Back
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Right Side of Mid Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Right Leg
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Left Hip
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Right Hip
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Headaches
Migraines
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Headaches
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Cluster
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Rebound
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Sinus
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Chronic Daily Headache
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Tension
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Neurological
Tingling
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Multiple Sclerosis
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Brain Injury
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Stabbing
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Cerebral-vascular Accident
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Cerebral Vascular Accident (Stroke)
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Sciatic Pain
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Loss of Sensation
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Seizure Disorder
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Stroke
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Transient Ischemic Attacks (TIA)
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Vertebral and Spinal Cord Injury
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Epilepsy
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Shingles
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Cerebral Palsy
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Huntington Disease
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Dizziness
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Parkinsons
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Brain Disorder
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Numbness
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Burning
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Herniated Disc
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Chronic Pain Disorder
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Emotions
Nervous
Depressed
Anxious
Easily angered
Easily irritated
Moody
Manic
Crying easily
Fearful
Grieving
Other __________________
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Cardiovascular
Cardiovascular Conditions
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Congenital Heart Defect
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Varicose Veins
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Heart Attack
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Blood Pressure
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Acute Coronary Syndrome
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Coronary Artery Disease
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Blood Clots
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Phlebitis
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Aneurysm
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Hyperlipidemia
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Lymphedema
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Cardiovascular Accident
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Angina
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Pericarditis
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Pacemaker
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Atherosclerosis
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Raynaud Disease
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Cold Hands
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Heart Disease
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Cardiac Arrhythmia
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Rheumatic Heart Disease
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High Blood Pressure
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Cold Feet
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Chronic Ischemic Heart Disease
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Valve Disorders
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Low Blood Pressure
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Chronic Venous Insufficiency
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Myocardial infarction
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Congestive Heart Failure
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Reproductive
History of STD/STI
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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
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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)
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Miscarriages: ____,_______ (#, most recent date) || How far along were you? __________ weeks
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Abortions: ____,_______ (#, most recent date)
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Abortions:
Medical
Personal
Decline to state
Never
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On this date ___________
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What kind? ___________
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I have been ‘trying’ for _____________ years/months
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Rounds of attempted IUI ______ when? ________________
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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?
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Any known fertility or OB/Gyn history of your mother or sisters?
Yes, findings__________
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No
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Using donor sperm
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Menstrual Cycle Disorder
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Ovarian Cysts/Tumors
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Pelvic Inflammatory Disease
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Premenstrual Syndrome
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Pregnancy
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Uterine Disorder
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Gynaecological Conditions
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Breast Disorder
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Ectopic Pregnancy
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Endometriosis
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Menopause
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Immune
Non-Hodgkin Lymphoma
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Rheumatoid Arthritis
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Anaphylaxis
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Allergies
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Lupus
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Hodgkin Lymphoma
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Infectious Mononucleosis
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Cancer
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Leukemia
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Musculoskeletal
Hereditary/Congenital Deformity
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Strain/Sprain
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Joint Injury
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Amyotrophic Lateral Sclerosis (ALS)
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Osgood-Schlatter Disease
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Osteoporosis
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Muscular Dystrophy
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Osteoarthritis
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Ankylosing Spondylitis
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Gout
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Osteomalacia
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Myasthenia Gravis
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Tendonitis/Bursitis
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Bone Disease
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Paget Disease
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Sinus Problems
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Compartment Syndrome
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Psoriatic Arthritis
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Artificial Joints / Special Equipment
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Dislocation
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Scleroderma
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Fibromyalgia
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Fracture
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Arthritis
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Jaw Pain (TMJD)
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Scoliosis
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Gastrointestinal
Constipation
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Digestive Conditions
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Poor Appetite
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Diarrhea
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Stomach Disorder
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Crohn's Disease
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Diverticulitis
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Ulcerative Colitis
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Eating Disorder
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Esophageal Disorder
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Fecal Impaction
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Intestinal Polyps
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Celiac Disease
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Irritable Bowel Syndrome
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Blood
Hypercoagulability
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Hepatitis
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Polycythemia
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Haemophilia
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HIV
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Thrombosis/Embolism
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High Cholesterol
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Anemia
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Bleeding Disorder
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HIV/AIDS
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Skin
Acne
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Athlete's Foot
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Psoriasis
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Allergic Dermatosis
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Rash
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Bruise Easily
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Athletes Foot
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Herpes
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Hypersensitive Reaction
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Rosacea
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Chemical Burn
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UV Burn
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Hypersensitive Reactions
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Melanoma
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Melanoma/Carcinoma
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Skin Conditions
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Infectious Skin Conditions
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Pigmentary Disorder
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Skin Irritations
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Plantar's Wart
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Respiratory
Chronic Cough
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Respiratory Conditions
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Shortness of Breath
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Asthma
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Tuberculosis
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Emphysema
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Bronchitis
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Respiratory Tract Infection
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COPD
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Cystic Fibrosis
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Infectious Respiratory Conditions
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Hearing
Conductive Hearing Loss
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Meniere Disease
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Motion Sickness
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Tinnitus
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Ear Problems
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Vertigo
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Hearing Loss
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Kidney
Renal Cysts
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Urinary Incontinence
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Urinary Tract Infection
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Bladder Disorder
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Chronic Kidney Disease
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Congenital Kidney Disease
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Electrolyte Imbalance
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Kidney Stones
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Endocrine
Acute Pancreatitis
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Diabetes
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Hyperthyroidism
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Hypothyroidism
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Pituitary and Growth Disorder
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Prostate Condition
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Family History
Arthritis
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Cardiovascular
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Respiratory
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Miscellaneous
Vision Problems
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Vision Loss
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Mental Health Issues
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Surgical Pins or Wire
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Insomnia
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Other Medical Conditions
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Other Diagnosed Diseases
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Medications
Medication
Add Another Medication
Injuries
Injury
Add Another Injury
Surgeries
Surgery
Add Another Surgery
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