ACUPUNCTURE PATIENT INFORMATION
NAME: _____________________________________________ Date: ______________
Best Phone #: ____________________________ Alternate Phone #: _______________________
Address: _____________________________________________ City/ST/Zip: ______________________________
Email____________________________________________ May we add you to our mailing list? ☐Yes ☐No
Age: _______ Birth Date: ____________ Marital Status:______________ Occupation:_________________________
EMERGENCY CONTACT/GUARDIAN:__________________________________ Phone: ____________________
Referred by:__________________________________________
Insurance Company:_____________________________ Social Security Number:________________________
Primary Member:________________________________ Policy Number:______________________________
Group Number:______________Provider Customer Service Phone Number:____________________________
I give my practitioner permission to bill my insurance company. If my claims are denied, I agree to promptly pay the
regular fee per service received. Signature:_____________________________________________
Current reason(s) for seeking treatment? _________________________________________________________
What results would you like to obtain? __________________________________________________________
How long have you had this condition? ___________________ Cause? ________________________________
What makes it better? ________________________________ Worse? _________________________________
Has this condition been diagnosed by an MD? ☐No ☐Yes, Diagnosis: _______________________________
Other professional treatments you are receiving:___________________________________________________
Other things you are doing to help yourself:______________________________________________________
Please list the medications, over-the-counter drugs, and supplements you are currently taking:
Medication/Supplement:
Reason for Taking:
Dosage:
When Prescribed?
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For your safety, your acupuncturist must know if you have any of the following conditions:
☐ Diabetes: Type 1 / Type 2 (circle) Blood Pressure:☐High ☐Low ☐Lymphedema ☐Anemia
☐Taking Blood Thinners/Coumadin/Warfarin
☐Cancer: _______________
☐Dizziness/Vertigo
☐PACEMAKER ☐Seizures ☐HIV/AIDS ☐Hepatitis A B C ☐Hemophilia ☐High Cholesterol
☐Stroke ☐Ulcer ☐Heart Disease ☐Kidney Disease ☐Thyroid Disease ☐Other:_________________
Women: Date of Last Period _________ Pregnant? ☐No ☐Yes ____________ Nursing? ☐ No ☐ Yes
Anything you wish to add? ___________________________________________________________________
_________________________________________________________________________________________
The above information is true to the best of my knowledge. If there is any change to my medical status or
medications, I will inform my healthcare provider. I have read/received the Privacy Practices Notice.
I understand that there is a 24-hour cancellation policy, and I may be billed for missed appointments.
Signature:____________________________________________________________ Date: ________________
Payment is due in full at time of service unless prior arrangements have been approved.
PLEASE CHECK ALL SYMPTOMS WHICH BEST DESCRIBE YOUR TENDENCIES IN THE PAST 6 MONTHS, OR
SPECIFY WHEN YOU EXPERIENCED THEM. These are significant even if they aren’t problematic for you!
BODY TEMPERATURE
TASTE & MOUTH
SLEEP
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Hot Body Temperature (sensation)
Cold Body Temperature (sensation)
Warm at night
Heat in Chest/Face/Palms
Hot Flashes
Cold Hands/Feet
Cold or Heat Sensations with Pain
SWEAT
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______ Profuse Sweat (with little activity)
______ No Sweat or very little sweat
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Spontaneous Sweat (w/out activity)
Night Sweats
Hands/Feet Sweat
Oily Sweat. With odor? Y N
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Thirsty Regularly
Thirsty with desire for cold drinks
Dry Mouth, Little Thirst
Dry Mouth & Thirst at Night
No Thirst or very little thirst
THIRST
DIGESTION
Bitter Taste in Mouth
Bland/Tasteless
Mouth Sores (canker)
Tongue Sores/Pain
Bleeding Gums or Gum Disease
Foul Breath
Dry Lips/Mouth
Profuse Saliva
Tooth Problems:_____________
DEFECATION
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HOURS PER NIGHT
Good Sleep/Feel Rested
Poor Quality Sleep
Insomnia
Insomnia w/ Restlessness
Difficulty Falling Asleep
Difficulty Staying Asleep
Restless Sleep/Light Sleeper
Intense Dreams
______ Wake to Urinate, #_____________
______ Easy back to sleep after waking
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Daily Bowel Movements: #_____
Irregular Stools: Every____Days
Alternating Loose/Hard Stool
Constipation
Dry Stool
Hard/Pebbly Stool
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Difficult back to sleep after waking
Deep Sleeper / Difficult Waking
Can Sleep All Day
Snoring
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Soft/Mushy Stools
Loose Stools
Loose Stool in Morning
Diarrhea
Undigested Food in Stool
Blood or Mucous in Stool
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High Energy, Good Stamina
Low Energy, Fatigue
Fatigue in the Afternoon
Exhausted After Sex
ENERGY & STAMINA
EMOTIONAL TENDENCIES
______ Painful Defecation
______ Irritability/Anger
______ Excessive Appetite
______ Low Appetite
______ Sudden Weight Gain or Loss
______ Pain after Defecation
______ Joy/Excitement/Talkativeness
______ Worry/Over-thinking/Pensiveness
______ Sadness/Grief/Crying
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Nausea/Vomiting
Stomach Pain
Hiccoughs
Gas
Bloating
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Frequent
Urgent
Clear/Profuse
Dark Color/Small Amount
Burning/Painful
______ Fear/Anxiety/Shock
______ Depressed/Unhappy
______ Indecisive/Lack of Direction
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Tired After Eating
Gurgling Sounds
Acid Reflux/GERD
Hiatal Hernia
Ulcers
Heart Burn
Belching
Mouth Sores (canker)
Other:___________________
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Cloudy Urine
Incontinence
Stress Incontinence
Nighttime Urination (#_______)
Frequent Bladder Infections
Blood in Urine
Kidney Infections or Stones
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PREFERRED FLAVORS
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2
Sour/Vinegar
Bitter/Tart
Sweet/Sugary
Pungent/Spicy
Salty
URINATION
SENSITIVE TO: (or dislike of...)
STRESS LEVEL
Wind
Heat
Dampness/Humidity
Dryness
Cold
Weather Changes
Favorite Season?______________
HEAD
______ Extremely High
______ High
______ Headaches, Location:________________
______ Migraines
______ Moderate / Normal
______ Low
______ Source of Stress:____________
______
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Poor Memory: Long Term or Short Term
Foggy Mind, Heavy Head
Mental Confusion
Dizziness
Head Injury or Stroke ___________
PATIENT SIGNATURE:_________________________________________
PLEASE CHECK ALL SYMPTOMS WHICH BEST DESCRIBE YOUR TENDENCIES IN THE PAST 6 MONTHS, OR
SPECIFY WHEN YOU EXPERIENCED THEM. These are significant even if they aren’t problematic for you!
EARS, EYES, NOSE, THROAT
BODY & LIMBS
WOMEN ONLY
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Ear Infections
Ear Ringing: High or Low Pitch?
Hearing Loss / Deafness
Ear Congestion or Discharge
Blurred Vision or Vision Impaired
Floaters in Vision/Black Spots
Dim Night Vision
Bloodshot Eyes or Burning Pain
Dry Eyes
Gritty Eyes
Glaucoma
Sinus Congestion
Nasal Discharge: Watery or Thick?
Sinus Infections Chronic
Nosebleeds
Sneezing
Allergies
Speech Problems
Sore Throat
Lump in Throat Sensation
Difficult Swallowing
CHEST, HEART, LUNGS
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Difficult Breathing
Shortness of Breath
Cough
Chest Pain
Chest Pain Radiating to Shoulder
Tightness in Chest/Rib/Side
Chest Congestion with Phlegm
Chronic Bronchitis
Frequent Sighing
Asthma
Pneumonia, When?____________
Breast Distention
Heart Palpitations
Mitral Valve Prolapse
Heart Condition: ______________
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Tingling Sensations
Numbness, Where?__________
Pain:____________________
______
Overall Body Aches
______
Arms/Legs Feel Heavy
______
Prolapsed Organs
Tight neck/shoulders
Breast Distention/Tenderness
Swollen Hands/Feet
______
Easy Broken Bones or Osteoporosis
______
Sore/Weak Knees
______
Low Back Pain/Weakness
______
Muscle Spasms or Cramps
______
Paralysis
Fibromyalgia
______
Hernia (abdominal)
______
Stroke
Paralysis
______
Lupus
______
Arthritis, Osteo- or Rheumatoid ______
______
______
SKIN & HAIR
Age at 1st period:__________
Age at menopause:_________
Pregnant? ______________
Nursing?
Birth Control?__________________
# of children:______________
Ages_____________________
Abortions
Miscarriages: #______________
Infertility, Since:_____________
Hysterectomy, ________________
Menopause Symptoms:_________
# days of Flow
# days of Cycle
Heavy periods
Light periods
Painful periods
Irregular periods
Bleeding Between Periods
______ Poor Circulation
______ Clots
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Dark Blood
Watery/Light color blood
Mucous with blood
Cramps Before Period
Cramps During Period
PMS
Pain/Achey after periods
Breast Tenderness
Fatigue During Period
Vaginal discharge (Circle Below)
Yellow, White, or Red/White?
______
______
______
______
Low Libido
High Libido
Fibroids
Endometriosis
Varicose Veins
Easy Bruising
Eczema or Hives
Hair Loss or Premature Graying
Brittle Nails
Skin Rashes
Hemorrhoids
Foot Fungus or Nail Fungus
Dry Skin
Acne
Warts
Cold Sores
Frequent Ingrown Hairs
Other:____________________
MEN ONLY
______ Impotence
PAIN, Location:_________________
______ Ovarian Cysts or PCOS
______ Since When?__________________
______ Radiates To:___________________
______ Sharp/Stabbing Pain
______ Prostate problems
______ Testicular pain
______ Testicular swelling
______ OTHER:_______________________
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3
Dull/Achey Pain
Better with Pressure or Exercise
Better with Rest
Better with Heat
Pain Comes and Goes
Cold/numb in genital area
Low Libido
High Libido
Premature Ejaculation
Other:___________________
HOSPITALIZATIONS/SURGERIES
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PATIENT SIGNATURE:_________________________________________