New PAtient/SErviceIntake Form Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Date of Birth MM DD YYYY Height Weight Gender Female Male Prefer Not to Answer Marital Status Single Married Divorced Widowed Emergency Contact Info Occupation Who can we thank for referring you to our office? Have you received Acupuncture Therapy before? Yes No Please indicate where you have pain: Briefly describe your symptoms: How and when did your symptoms start? How often do you experience your symptoms? Constantly - 76%-100% of the time Frequently - 51% - 75% of the time Occasionally - 26% - 50% of the time Intermittently - 0%- 25% of the time In general, would you say your overall health right now is.. Excellent Very Good Fair Poor What are the main health problems for which you are seeking treatment? What other forms of treatment have you sought out? any other health problems or concerns you have? Thank you!
