Acupuncture Intake Form

Information you will need

• What’s your age?
• What’s your date of birth?
• What's your home phone number?
• What's your cell phone number?
• What's your email address?
• What's your address?
• What's your occupation?
• What's your marital status?
• Who's your emergency contact?
• What's the emergency contact's phone number?
• What's your primary care physician's name?
• Are you or your spouse a veteran?
• Who were you referred by?
• How does this problem affect your daily activities?
• When did you first notice symptoms?
• Are there any painful or distressed areas on you body?
• How would you describe your exercise level?
• Are you taking any drugs, herbs, or supplements?
• PARENT/GUARDIAN ONLY: What’s your full name?
• What are your health concerns?
• What diagnoses and treatments or therapies have you received?
• Do you have any allergies?
• What's your primary care physician's phone number?
• PATIENT ONLY: What’s your name?

…and 5 more fields in the PDF.

The form includes 2 signature lines, a notary acknowledgment.