Acupuncture Intake Form

Page 1

Name

First Name

Last Name

Date of birth

Address

Street Address

City

State / Province

ZIP / Postal Code

Email

Phone number

What is your current gender identity?

Male Female Non-binary Other

Describe (if other)

Marital status

Single Married Divorced Widowed

Occupation/employment status

Emergency contact (or legal guardian if under 18)

Street Address

City

State / Province

ZIP / Postal Code

Page 2

Do you have a cardiac pacemaker or other implanted electronic device?

Yes No

Do you have epilepsy or a seizure disorder?

Yes No

Women only: are you currently pregnant or planning to become pregnant?

Yes No Not applicable

Surgeries, major procedures, major illnesses, and/or hospitalizations, with dates

List all medications you take and the reason for taking them

Allergies/sensitivities (food, drugs, or environmental): latex, fragrance, seasonal, other

Major diseases that run in your family

Page 3

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I have read and understood the information provided about acupuncture and its potential risks and benefits, and I consent to receive acupuncture treatment.

Patient name

Acupuncturist name

Patient signature

Sign here

Today's date

Page 5

Patient name

I understand that I am responsible for the costs of my treatment and that these fees will be charged regardless of my health insurance coverage.

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