New Acupuncture Patient Form - Lander Chiropractic

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Patient Data

Patient Name(Required)

Birth Date(Required)

Month

Day

Year

Gender(Required)

Male

Female

Mailing Address

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Home Phone

Email(Required)

Referred By

Employer

Occupation

Current Complaints

Reason for seeking treatment?(Required)

Date Symptoms Started?(Required)

Month

Day

Year

Do you have medical insurance that covers acupuncture?(Required)

yes

Please check all areas of current pain:(Required)

Head

Neck

Jaw

Shoulder

Arm

Elbow

Wrist

Hand

Upper Back

Lower Back

Tailbone

Hip

Thigh

Knee

Ankle

Foot

Chest

Abdomen

Other

Please list other area(s) of pain(Required)

Please check your pain level (0=no pain and 10=unbearable pain)(Required)

How often are your symptoms present?(Required)

Constantly

Frequently

Intermittently

Occasionally

Describe your current health condition?(Required)

Good

Fair

Poor

Chronically Ill

Can you perform all your daily activities?(Required)

Yes, all activities

Some activities

Not at all

Are you currently under the care of a physician?(Required)

Yes

What treatments, if any, have you received for the condition you’ve come to us for? (Surgery, medications, chiropractic, etc. - if none, enter none)(Required)

Past & Present Medical Issues

Alcohol/tobacco/drug dependence

Past

Present

Abnormal menstruation

Past

Present

Allergies

Past

Present

Angina

Past

Present

Arthritis/rheumatoid arthritis

Past

Present

Artificial joints

Past

Present

Asthma

Past

Present

Blood disorder

Past

Present

Breast lumps

Past

Present

Cancer/tumor

Past

Present

Convulsions/seizures

Past

Present

Diabetes

Past

Present

Diarrhea/constipation

Past

Present

Excessive thirst

Past

Present

Fainting or dizziness

Past

Present

Rapid weight gain/loss

Past

Present

Frequent urination

Past

Present

Headache

Past

Present

Heart attack

Past

Present

Heartburn/Indigestion

Past

Present

High blood pressure

Past

Present

Hospitalizations

Past

Present

Surgical procedures

Past

Present

Please describe any surgical procedures(Required)

Kidney disease

Past

Present

Liver problems

Past

Present

Pacemaker

Past

Present

Painful menstruation

Past

Present

Palpitation/arrhythmia

Past

Present

Peptic ulcer

Past

Present

PMS

Past

Present

Pregnancy

Past

Present

If pregnant, how many months?

Sinusitis

Past

Present

Stroke

Past

Present

Thyroid

Past

Present

Medical History

What medications are you taking and for what conditions (Please list dosage and amounts, etc). If none, please type none.(Required)

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

Arthritis

Lupus

Cancer

Heart Disease

Mental Illness

Hypertension

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.

Signature

Date

Month

Day

Year