Patient Information

Name:

Date of Birth:

Age:

Submitted:

Email:

Preferred name / pronouns:

Sex assigned at birth:

Gender identity:

Address: , , 

Cell:

Phone:

Occupation:

Relationship status:

Emergency contact: - 

Primary care physician:

How did you hear about us:

Best way to reach:

Reason for Your Visit

Condition due to:

If other:

Had acupuncture before:

Interested in treatment plan:

Chief Complaint

Main issue:

Pain level today (0-10):

Location(s):

Began:

M.D. diagnosis:

Treatments tried / results:

Lifestyle

Caffeine/day:

Alcohol/week:

Tobacco/vape:

Exercise:

Sleep:

Stress level:

Diet notes:

Medical History

Significant illnesses:

Other illnesses:

Operations:

Allergies:

Accidents / trauma:

Medications & supplements:

Safety Screening

Flags:

Pregnancy & Menstrual Screen

Pregnant:

Weeks: 

Nursing:

Last menstrual period:

TCM Review of Systems

Temperature & Sweating:

Digestive (Spleen/Stomach):

Sleep & Shen (Heart):

Emotional/Stress (Liver):

Respiratory (Lung):

Urinary/Reproductive (Kidney):

Pain:

Thirst/Fluids:

Yin/Yang Indicators:

Review of Systems

General:

  Other:

Skin & Hair:

  Other:

HEENT:

  Other:

Cardiovascular:

  Other:

Respiratory:

  Other:

Gastrointestinal:

  Other:

Genitourinary:

  Night urination / frequency / color:

  Other:

Reproductive & Gynecologic:

  Last menses:

Musculoskeletal:

  Other:

Neuropsychological:

  Treated for emotional/mental-health concerns:

Anything Else

Signature Authorization

Form completed and signed by:

Patient representative (if signing for the patient):

Relationship to patient:

Patient under 18 years of age:

If signed by a representative, the signer represents that they are the patient’s parent, legal guardian, or authorized representative with authority to consent to care for the patient.