BE New Patient Intake Form

Balanced Energetic
New Patient Information Form

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Full Name

First NameMiddle NameLast Name

E-mail

Gender

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Format: (000) 000-0000.

Occupation

Emergency Phone Number

Area CodePhone Number

Emergency Contact

First NameLast Name

Marital Status

Number of Chldren

Have You Received Acupuncture Before?

List Any Environmental And/Or Drug Allergies Here:

Medical History

What are the main health problems for which you are seeking treatment? List in order of importance.

1.

About when did it start?

MonthDayYear

2.

About when did it start?

MonthDayYear

3.

About when did it start?

MonthDayYear

4.

About when did it start?

MonthDayYear

Main Complaint (please describe in more detail):

If complaining of pain, how do you describe your pain? Check all that apply.

Does the pain radiate to other places? Please Explain.

What factors worsen your pain?

What factors decrease your pain?

Is your pain resulting from an accident?

Investigations done so far:

Other

Treatments received up-to-date for your current problem:

List all medications taken now for any reason:

Check all treatment received in the past or being currently received:

Smoking: Packs per day, for how long, and/or when did you quit?

Alcohol: How many glasses per week, and/or when did you quit?

Coffee/Tea/Caffeine: How many cups/cans daily? For how many years?

Recreational drug use: Check all that apply

Family History:

General: Check all that apply

Cardiovascular:

Respiratory:

Gastro-Intestinal:

Endocrine:

Urinary:

For Women

Pregnancies

Children

Normal/Abnormal

Age Periods Started:

Periods:

Length of Cycle:

Duration of flow:

Age at menopause:

For Men

If other, describe:

Musculo-Skeletal:

If other, describe:

Neurological:

If other, describe:

List if All Surgical Operations:

1.

When?

MonthDayYear

2.

When?

MonthDayYear

3.

When?

MonthDayYear

4.

When?

MonthDayYear

How Severe Is Your Pain? (1=No Pain, 10-Unbearable)

At Rest?

With Activity?

Please mark where you feel pain. Use Blue for Aching. Red for Burning. Orange for Stabbing. Purple for numbness, and Green for Pins and Needles. If you can, indicate which direction the pain travels. (If the image won't load, please skip this part. )

Please type what you see in the field below so that we can ensure that you are a real person!

Done!

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