Acupuncture intake form

Patient Name _________________________________________ Today’s Date ____________________ Have you ever had acupuncture before? □ Yes □ No When? ________________________________
MAIN COMPLAINT
Please describe your reason(s) for this appointment: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ When did you first notice this problem? ______________________________________________________ Has this ever happened before? ____________________________________________________________ Symptoms developed from: □ injury □ illness □ gradual onset □ unknown causes Symptoms: □ come and go □ are constant □ are getting worse Have you been given a diagnosis for this problem? _____________________________________________ What makes it better? ____________________________________________________________________
What makes it worse? ____________________________________________________________________

MEDICAL HISTORY

□ Anemia □ Anxiety/Depression □ Asthma □ Cancer ________ □ Chronic Fatigue □ Crohn’s/Ulcerative Colitis □ Diabetes □ Eating Disorder □ Epilepsy/Seizures □ Heart Disease □ Hepatitis ________ □ High Blood Pressure □ Hypo/Hyperthyroid □ Kidney Disease □ Migraines □ Pneumonia □ Shingles □ Stomach Ulcers □ STD □ Stroke □ Tuberculosis □ Other _____________
Please check any of the following statements that are TRUE:
□ I am taking coumadin/warfarin/heparin. □ I am taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs). SYMPTOM SURVEY
Please check off all that applies to you within the last three (3) months:
FOR MEN ONLY
Manual prostate exam results: + or –
Frequency of Urination: Daytime _______ Nighttime _______ Color of Urine: □ Clear □ Cloudy □ Presence of blood Odor: _________________ Do you experience any of the following symptoms? (Please circle.)
Delayed stream Dribbling Incontinence Retention of urine Impotence Rectal dysfunction Increased libido Decreased libido Premature ejaculation Painful urination Low back pain Groin pain Testicular pain Other ______________________________

FOR WOMEN ONLY
Age of 1st period ____________ Age of menopause (if applicable) ___________ Number of days between periods _________ Number of days of flow _________ How heavy is the flow (bleeding)? □ Light □ Medium □ Heavy Color of flow (blood): □ Light red □ Red □ Dark red □ Brown □ Black Do you experience any of the following symptoms? (Please circle.)
Acne Bloating Breast Tenderness Constipation Cramping Decreased Appetite Decreased Libido Diarrhea Headache Hot Flashes Increased Appetite Increased Libido Insomnia Irritability Low Back Pain Mood Swings Nausea Night Sweats Vaginal Discharge Vaginal Dryness Have you been diagnosed with:
Uterine Fibroids Fibrocystic Breasts Endometriosis Uterine Polyps Pelvic Adhesions Pelvic Abnormalities Chlamydial Infection Pelvic Inflammatory Disease Ovarian Cysts Polycystic Ovaries (PCOS) Other___________________ Date(s) of your LAST:
Gynecologic Exam ______________ Normal / Abnormal Pap Smear ____________________ Normal / Abnormal Mammogram __________________ Normal / Abnormal Are you pregnant? □ Yes □ No □ Trying to conceive
# of Pregnancies _____ # of Live Births _____ # of Abortions _____ # of Miscarriages _____ Birth control use? □ Yes Type:_________________ Consent to Treatment
By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or Chinese Herbal Medicine by an
acupuncturist and Chinese herbalist who is licensed by the state of Massachusetts, and practicing at ISIS Holistic Clinic. I
understand that acupuncturists practicing in the state of Massachusetts are not primary care providers and that regular
primary care by a licensed physician is an important choice that is strongly recommended by this clinic’s practitioners.
Acupuncture: I understand that acupuncture is performed by the insertion of needles through the skin at certain points on or
near the surface of the body at various depths and locations. Application of this technique may work to treat bodily
dysfunction or diseases, to modify or prevent pain perception, and to promote health by balancing the body’s physiological
functions. I am aware that certain adverse effects may result, such as local bruising, minor bleeding, pain or discomfort,
fainting, or the possible aggravation of symptoms existing prior to acupuncture treatment. Acupuncture may induce feelings
of deep relaxation, or rarely lightheadedness, and therefore, I should not have a treatment on an empty stomach. I
understand that no guarantee can be made concerning the results of treatment.
Moxibustion: I understand that moxibustion is a technique involving burning of the processed herb, mugwort (Artemesia
vulgaris), which may be done above the skin, on the needle, or directly on the skin. This technique is administered to treat
bodily dysfunction or disease, to modify or prevent pain perception, and to promote health by balancing the body’s
physiological functions. I understand that if I receive moxibustion as part of therapy, there is a risk of burning or scarring
from its use.

Electro-Acupuncture: I understand that electro-acupuncture may be used to enhance a treatment when necessary. I
understand EA is the use of a small, battery-operated stimulator that is attached to the end of the needles to produce a slight
vibrating or twitching sensation in the muscle or around the needle. I am aware that conditions may be exacerbated
temporarily during this healing process.

Acupressure/Tui-Na, Cupping, Gua Sha: I understand that I may also be given acupressure/tui na, cupping, or gua sha
as part of my treatment to modify or prevent pain perception and to balance the body’s physiological functions. I am aware
that certain adverse effects may result from this technique, such as sore muscles or aches, local bruising, or the possible
aggravation of symptoms existing prior to treatment.

Electromagnetic Heat Lamp: I understand that heat from electromagnetic waves may be used during the treatment to
warm up certain areas of the body. I am aware that certain adverse effects may result from this therapy, such as itchiness,
redness, or the possible aggravation of symptoms existing prior to treatment.

Press Ball/Ear Seeds: I understand that press balls/ear seeds, which are small steel balls, may be taped to specific ear
points following treatment. I am aware that the press balls/ear seeds should be removed and discarded if any irritation or
discomfort occurs. Otherwise, they can be left in place for the number of days recommended by the practitioner.
I understand that it is my responsibility to inform my acupuncturist if I become pregnant or suspect that I am pregnant before
each treatment begins.
I have carefully read and understand all of the above information and am fully aware of what I am signing. I understand that
I may ask my practitioner for a more detailed explanation. I understand that I have the right to refuse any of the
aforementioned therapies/techniques at any time during the course of treatment(s) and that no guarantee can be made
concerning the results of treatment. I give my permission and consent to treatment.

Signature of Patient: X________________________________________ Date:_____________________

Printed Name of Patient: ______________________________________

Source: http://www.isisboston.com/assets/Uploads/Acupuncture-Intake-Form.pdf