Patient Intake

Collier Acupuncture

Add your personal information and experiences to the fields below. Your responses will be used to determine treatments catered to your needs. Please answer honestly and include details. If you are unsure of an answer or it does not apply to you, please note it in the response field.

Name

Your First and Last name.

Age

How old are you?

Height

Feet' and Inches"

Weight

Pounds

Date of Birth

Month

Day

Year

Contact Infromation

Cell Phone Number

Your personal number is best for calling and texting.

Personal Email

Use an account you check often.

Emergency Contact Phone Number

This person will be called in medical emergencies, and if transport is needed.

Emergency Contact Name

Their First and Last name.

Emergency Contact Relationship

How are they related to you? Relative, caregiver, close freind, ect.

Physcial Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Home Phone Number

Notify others in your household if you are expecting calls.

Work Information

Occupation

What do you do for work?

Do you enjoy work? Explain why or why not.

Discuss how work affects you physically and mentally.

Work Phone Number

Make sure you have permission from your employer to take calls from this number.

Medical Infromation

Name of your Primary Care Provider

Are you under the care of any other health care providers? If YES explain what they offer you?

Have you experienced any major traumas? If YES explain (include dates)

What diagnosis have you been given?

What kinds of treatment have you tried?

Have you had acupuncture before? If YES, explain your history.

List any surgeries, significant injuries, broken bones, etc. (include dates)

List any medications, drugs, herbs or supplements you are taking

List any allergies or sensitivities to any medications, foods, or other substances

What is your primary reason for seeking treatment?

When did the problem begin? Have you experienced these concerns before?

Include dates if possible.

Which option best describes your condition overall?

Coming & going

Staying consistent

Getting worse

List what makes your condition BETTER and relieves pain.

List what makes your condition WORSE and causes pain.

Signing

I understand that I am responsible for payment of my account, and that payment is due at the time services are rendered.

I have read (or had read to me) the information above. I have honestly answered all questions to the best of my ability.

Signature

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Sign your first and last name in cursive.

You may draw, type, or upload a photo of your signature.

Today's Date

Month

Day

Year