Acupuncture Intake Form

Page 1

Name

Nombre

Apellido

Date of birth

Address

Dirección

Ciudad

Estado / Provincia

Código postal

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)

Dirección

Ciudad

Estado / Provincia

Código postal

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

Page 4

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