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New Patient - Acupuncture & Chinese Herbal Medicine Information Form
Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All answers are confidential.
If someone referred you to us, whom specifically may we thank?
What symptoms/conditions bring you in today?
Other problems/concerns to be addressed:
How long have you had this condition?
Have you experienced this before? YES NO
What seemed to be the initial cause?
What seems to make it better?
What seems to make it worse?
Does it bother your: Sleep Work Other:
Complete for each family member, indicating any of the illnesses that they have ever had. Check in the appropriate box(es).
PERSONAL LIFESTYLE HABITS
(how much, how many, or how often).
Cigarettes (packs): Coffee/Tea (cups):
Other recreational drugs:
Vitamins & Herbs:
DIET: What might you eat on a typical day?
What non-work activities do you enjoy doing? (Reading, TC, meditation, etc.):
Using the images above and letters below, please indicate which areas are of concern (for example pain and tenderness in the right area of the head would be notated by 1-O):
Pain and Tenderness = O
Numbness and Tingling = Z
Swelling and Stiffness = X
The information I have provided is true and correct to the best of my ability.
(draw your signature)