RN Acupuncture



Client Intake Form

Thank you for choosing RN Acupuncture. To best serve you, please fill out the following. All information will be kept confidential in accordance with HIPPA regulations. Please print clearly.

Name:______________________________________ Today’s Date:________________________________

Birth Date:_________________ Age:________ M or F__________ E-Mail_____________________

Address:____________________________________ City:_____________ State:______ Zip___________

Phone: (H)_______________ (W)_________________ (C)_______________________

Height:________________ Weight: __________________ Allergies:____________________

Marital Status:__________ Ages of Children:________________

# of Grandchildren:_____________ Occupation:________________________

How did you hear about RN Acupuncture?________________________________________________

List other health practitioners and their specialty (i.e. chiropractor, gynecologist, psychotherapist, nutritionist)_______________________________________________________________

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List all hospitalizations or surgeries with year:___________________________________________

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List all current medications with dosage:__________________________________________________

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List current dietary supplements (i.e. vitamins & herbs):________________________________

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Describe your physical exercise routine:___________________________________________________

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Recent Tests (check all that apply):

___ Cholesterol ___Blood ___X-Ray ___MRI ___Biopsy ___Colonoscopy ___Endoscopy ___PSA ___Mammogram ___Pap Smear ___Bone Density ___EKG ___Ultrasound ___Other___________________ Date and Results:_____________________________

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Have you ever been anemic?___________ If yes, when?______________________________________

Do you have a pacemaker?___________

Do you have unusual sensitivity to heat?__________________________________________________

What season do you prefer?_______________

Do you feel a frequent lump in your throat?_______________________________________________

What hours and how well do you sleep?________________________________ Do you awaken at night to urinate?___________ If so, how many times?____________________________________

How is your energy level?_____________________ Do you have a “low energy” time of day?_____________ If so when?________________________________________________________________

Do you often feel cold when others don’t?_________________________________________________

Do you experience mood fluctuations?_____________________________________________________

Which emotion do you feel most often:

___Grief ___Fear ___Anger ___Anxiety ___Worry

Are you under a lot of stress?______ If yes, please describe:______________________________

Do you follow a special diet?______ If yes, which one and for how long?_________________

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What do you typically eat for breakfast?___________________________________________________

What do you have for lunch?________________________________________________________________

What do you eat for dinner?_________________________________________________________________

How many servings of dairy do you eat a day?______________________________

What kind of snacks do you eat?____________________________________________________________

Which flavor do you crave the most?

___Sweet ___Salty ___Sour ___Bitter ___Spicy/Pungent

Are you frequently thirsty?________ Do you prefer hot or cold drinks?__________________

How much water do you drink a day?_____________________________________________________

How often and in what form do you consume caffeine?__________________________________

How many alcoholic beverages do you consume a day?__________ Week?_______________

Do you smoke cigarettes?_____ Do you vape nicotine? If yes, how much and for how long?_____________________________________________________________________________________

Have you tried to quit?______ If yes, please describe:_____________________________________

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Do you want or need to lose weight?_____ If yes, how much?____________________________

Please check any of the following medical conditions that apply to you now or in the past:

___AIDS/HIV ___Fibromyalgia ___Multiple Sclerosis

___Alcohol Addiction ___Flu-like symptoms ___Mumps

___Allergies ___Frequent Colds ___Osteoporosis

___Asthma ___Gall Stones ___Pancreatitis

___Anemia ___Gallbladder Disease ___Pleurisy

___Arthritis ___Goiter ___Pneumonia

___Bladder Infections ___Gynecologic Problems ___Polio

___Bleeding Tendency ___Heart Attack ___Pregnant Currently

___Blood Clots ___Heart Palpitations ___Rheumatic Fever

___Blood Transfusions ___Hemorrhoids ___Scarlet Fever

___Bone Disease ___Hepatitis/Jaundice ___Sciatic Pain

___Bronchitis ___Herpes ___Scoliosis

___Bursitis ___High Blood Pressure ___Spinal Meningitis

___Cancer or Tumor ___High Cholesterol ___Stomach Ulcers

___Chicken Pox ___Hives ___Stroke

___Chronic Fatigue Syndrome ___Hyperthyroid ___Tendonitis

___Colon or Bowel Disease ___Kidney Stones ___Tuberculosis

___Compulsive Disorder ___Kidney Infection ___Urinary Problems

___Coordination Difficulty ___Liver Disease ___Varicose Veins

___Diabetes ___Low Blood Pressure ___Venereal Disease

___Drug Addiction ___Lupus ___Other______________

___Drug Sensitivity or Reaction ___Lyme’s Disease ________________________

___Emotional Problems ___Migraines ________________________

___Emphysema ___Mononucleosis ________________________

Family History: Please check any that applies.

___Alcoholism ___Epilepsy ___Thyroid Disease

___Allergies ___Glaucoma ___Other______________

___Anemia ___Gout ________________________

___Arthritis ___Heart Disease ________________________

___Asthma ___High Blood Pressure ________________________

___Cancer ___Mental Illness ________________________

___Diabetes ___Stroke ________________________

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