New Patient Intake Form

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday

MM

DD

YYYY

Have you had acupuncture before?

Yes

No

Phone number

(###)

###

####

Check any symptoms that apply to you

Aversion to cold

Depression

Difficulty with mental focus

Dizziness

Easily startled

Excessive worry

Excessive anger

Excessive fear

Fainting

Fatigue/tiredness

Frequent dreams/nightmares

Headaches

Loss of sleep/poor sleep

Loss or gain of weight

Nervousness/irritability

Overwhelmed by life

Thirst

Conditions you have or have had in the past

Anemia

Bleeding disorders

Cancer

Psychiatric Disorder

Allergies

Seizures

Arthritis

HIV/AIDS

Breast Lump

Diabetes

Hepatitis

Other

Check if you experience any of the following

Tremors or Cramps

Seizures

Swollen joints

Difficulty walking

Check if you experience pain / weakness / numbness in any of the following

Arms

Hips

Back

Legs

Feet

Neck

Hands

Shoulders

Other

Check if you experience any of the following

Asthma/wheezing

Blurred or failing vision

Change in smell

Change in taste

Decreased hearing

Difficulty swallowing

Difficulty breathing

Earache

Enlarged glands

Eye pain / inflammation

Frequent colds

Hay fever

Hoarseness

Gum trouble

Nose bleeds

Oral ulcers

Loss of hearing

Persistent cough

Poor night vision

Ringing in ears

Sinus problems

Spots in visual field

Sore throat

Visual changes

Check if you experience any of the following

Boils

Bruise easily

Changes in mole / lump

Dry skin

Eczema

Itching/rash

Sensitive skin

Sores that won't heal

Excessive sweating

Night sweating

Check if you experience any of the following

Chest pain or tightness

Hardening of arteries

High or low blood pressure

Poor circulation

Palpitations

Phlebitis

Previous heart attack

Rapid/irregular heart beat

Check if you experience any of the following

Acid Reflux

Excessive Belching

Flatulence

Bloating

Blood in stool or black stool

Colon trouble

Constipation

Diarrhea

Difficulty swallowing

Distention of abdomen

Excessive hunger

Food Cravings

Gall bladder trouble

Hemorrhoids (piles)

Indigestion

Nausea

Pain over stomach

Poor appetite

Recent change in weight

Vomiting

Check if you experience any of the following

Erectile dysfunction

Prostate enlargement

Weak urinary strength

Testicular lumps

Check if you experience any of the following

Abnormal PAP smear

Bleeding between periods

Breast Lumps

Clots in menses

Excessive menstrual flow

Extreme menstrual pain

Frequent urinary tract infections

Frequent vaginal infections

Irregular cycle

Menopausal symptoms

PMS

Previous miscarriage

Scanty menstrual flow

History of PID or Endometriosis

Are you trying to become pregnant

Yes

No

Is there any possibility you are currently pregnant?

Yes

No

Confirmation *

I have read and understand this consent to treatment, have been told about the risks and benefits of acupuncture and other procedures. Ms. Leclair has explained the procedures to me so that I fully understand, and I have had the opportunity to have my questions answered by her. No guarantee of successful treatment has been implied. I understand that I am entitled to a copy of this consent form upon request and that I may withdraw this consent upon request in writing at any time.

By checking this box I confirm I have read the above and consent to treatment.