Today's Date   /   / New Patient Intake Form
Name SS#               Birthdate     /___ /____
Marital Status         Age      
Street Address                       M     F     Ht ______       Wt ______
City, State, Zip email:
Home Phone                 Work Phone           Occupation            
Emergency Contact Name & Phone
Referred by                                                  
Reason for visit today Have you had acupuncture Chinese herbal
before?   Yes   No medicine?   Yes   No
How long have you had this condition?                                        
Is it getting worse? Does it bother your:   Sleep   Work   Other (what?)
What seemed to be the initial cause?                                        
What seems to make it worse?
Are you under the care of a physician now?         Yes     No     If yes, for what?          
Who is you physician Physician's Phone:
Other concurrent therapies                                            
Health Insurance Info:
Insurance Co. Name Policy No.
Street Address                             Phone                  
City, State, Zip                                                  
Medicare Info:
Insurance Co. Name Policy No.
Street Address                             Phone                  
City, State, Zip                                                  
Family Medical History                                            
Allergies   Arteriosclerosis   Cancer   Diabetes   Seizures
          Asthma             Heart Disease   Stroke
  Alcoholism   Night Blood Pressure
                                                     
Your Past Medical History                                            
  AIDs/HIV   Diabetes   Multiple Sclerosis   Surgery (list)   Tuberculosis
  Alcholism   Emphysema   Mumps             Typhoid Fever
  Allergies   Epilepsy   Pacemaker             Ulcers
  Appendicitis   Goiter   Pleurisy             Veneral Disease
  Arteriosclerosis   Gout   Pneumonia   Thyroid Disorders   Whooping Cough
  Asthma   Heart Disease   Polio   Major Trauma   Other (Specify)
  Birth Trauma   Hepatitis   Rheumatic Fever (Car, fall, etc-list)            
  (your own)   Herpes   Scarlet Fever                      
  Cancer   High Blood Pressure   Seizures                      
  Chicken Pox   Measles   Stroke
                                                     
Your Diet                                                  
Appetite
  Low   Coffee   Artificial   Sugar Thirst for water:
  High   Soft Drinks Sweetener   Salty Food # of glasses per day:  
Average Daily Menu                                              
Morning Snack Noon Snack Evening Snack
                                           
                                           
                                           
Pharmaceuticals taken in last 2 months (continue on back if needed):
Vitamins/supplements taken in last 2 months: