New Patient Health Information Form

Have you ever been treated with acupuncture before? *

Yes, I have

No, I haven't

If yes, for what condition(s):

CHIEF COMPLAINT

What is your primary reason for this visit? *

When did your symptoms first begin? *

Are symptoms constant or intermittent? *

What other treatments have you tried for this condition? *

What aggravates the condition? *

What alleviates the condition? *

MEDICAL HISTORY

Other diagnoses or health issues affecting your or health: *

List any serious diseases, injuries, traumas, or hospitalizations and when they happened: *

Please explain if necessary: *

Do you have any implants, joint replacements, heart pacemakers, or other devices? *

Yes

If yes, please explain:

Please list your current medications, when you started taking them, and the reason for taking the medication: *

Please list supplements / herbs that you are taking and the reason for taking them: *

PATIENT ALLERGIES AND SENSITIVITIES

Do you have any allergies or sensitivities to drugs, foods, environmental irritants, or other substances?* *

Yes

Please explain your allergies: *

FAMILY HISTORY

List significant illnesses such as easy bleeding, diabetes, cancer, alcoholism, obesity, heart disease, allergy, epilepsy, high blood pressure, mental illness, stroke, etc:

Father:

Mother:

Siblings:

Children:

Grandparents:

LIFESTYLE AND HABITS

Do you have a habit to smoke?

Yes

Please explain if necessary:

Do you have a habit to chew tobacco?

Yes

Please explain if necessary:

Do you have a habit to drink alcohol?

Yes

Do you have or think you may have any addiction?

Yes

If so, please explain:

Are you physically active on a regular basis?

Yes

If so, what type of activity and how often?

How much does stress affect your life on a 0-10 scale (10 = extreme stress)?

What are current major stressors in your life?

What is your job satisfaction level on a 0-10 scale (10 = extremely satisfied?)

How many hours per week do you work?

What is your favorite recreational activity?

What are your goals for your health?

What is your level of commitment to improving your health on a 0-10 scale (10 = 100% committed)?

Verification*

I certify that the information that I have given above is correct and accurate to the best of my knowledge.

Patient Name *

Email *

Signature *

Clear

If signed by patient representative, state relationship to patient: