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New Acupuncture Patient Form

Home/New Acupuncture Patient Form
New Acupuncture Patient FormKurt Abel2021-09-23T19:21:53+00:00

Step 1 of 6

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Patient Data

Birth Date(Required)
Gender(Required)

Mailing Address

Address(Required)

Current Complaints

Date Symptoms Started?(Required)
Do you have medical insurance that covers acupuncture?(Required)
Please check all areas of current pain:(Required)
Please check your pain level (0=no pain and 10=unbearable pain)(Required)
How often are your symptoms present?(Required)
Describe your current health condition?(Required)
Can you perform all your daily activities?(Required)
Are you currently under the care of a physician?(Required)

Past & Present Medical Issues

Alcohol/tobacco/drug dependence
Abnormal menstruation
Allergies
Angina
Arthritis/rheumatoid arthritis
Artificial joints
Asthma
Blood disorder
Breast lumps
Cancer/tumor
Convulsions/seizures
Diabetes
Diarrhea/constipation
Excessive thirst
Fainting or dizziness
Rapid weight gain/loss
Frequent urination
Headache
Heart attack
Heartburn/Indigestion
High blood pressure
Hospitalizations
Surgical procedures
Kidney disease
Liver problems
Pacemaker
Painful menstruation
Palpitation/arrhythmia
Peptic ulcer
PMS
Pregnancy
Sinusitis
Stroke
Thyroid

Medical History

If a family member has had any of the following, check all that apply

PLEASE READ AND SIGN IF YOU WISH TO BE TREATED WITH ACUPUNCTURE OR ACUPRESSURE.

I, the undersigned, fully understand that no therapeutic treatment, including these, can carry with it any stated or implied guarantee of success. I also understand that these treatments may produce some slight bruising and I release Mike Worley, L.Ac. from responsibility in the event that that should occur.
Date

About Us

We want to empower you to take control of your health as it is our desire to assist you and your family in achieving optimum health, wellness, and longevity.

Lander Chiropractic

1203 Imperial Hwy #100
Brea, CA 92821
Phone: (714) 931-0475
Fax: (714) 582-1727

Main Office - Brea

Click to open a larger map

Office Hours

Monday - Saturday by appointment only. No walk-ins.

Our Services

Pages

  • Acupuncture
  • Bloom Attendee Raffle
  • Chiropractic Care
  • Chiropractic Care for Children
  • Chiropractic Care for Sports Injuries
  • Home Exercise Recommendations
  • New Acupuncture Patient Form
  • New Patient Form – Personal Injury
  • New Patient Form – Pregnancy
  • New Patient Health History Form
  • New Pediatric Patient Health History Form
  • Pregnancy Care
  • Safety & Support – Your Health & Concerns Matter To US: COVID-19 Response
  • Story Time With Dr. A

Connect With Us!

We are ICPA Certified

Copyright 2017 Lander Chiropractic | All Rights Reserved | Website by Two Cans Media
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