Acupuncture/Chinese Medicine Client Information

Name: ___________________________

Date of Birth: ________________________

Phone #: _________________________

Admission Date: ______________________

Address: _________________________________________________________________
Complaint: _______________________________________________________________
Referred by: ______________________________________________________________
Medical History:
Have you ever had:

Have you ever had or do you now have:

Yes No (check each item)

Yes No

(check each item)

Sinusitis

Hay Fever

Heart Attack

Chest Pain

Stomach, Liver or Intestinal Trouble

Asthmatic Wheezing

Tumor, Growth, Cyst, Cancer

Indigestion

Sugar or Albumin in Urine

Painful Joints

Any Drug or Narcotic Habit

Back Pains

Anxiety/Stress/Emotional Problems

Neck Pains
Headaches
High Blood Pressure

Female Only: Are you currently

Nervousness

Pregnant

Auto Accident Related Problems

Nasal/Skin Allergy

Medications/Operations (Please list all performed and your age when each was performed):
_________________________________________________________________________
_________________________________________________________________________

X-Rays: __________________________________________________________________
Treatment (Radiation, PT/OT, Chemotherapy and Psychotherapy etc.)
_________________________________________________________________________
_________________________________________________________________________

I understand that the acupuncture treatments are safe. All needles are made with surgical
steel, are sterile and only disposable needles are used. There is no medication in the
needles.
I understand that during acupuncture treatments, there will be a feeling of slight pain
when the needle punctures the skin. Sometimes there may be slight bleeding at the points
where needles are removed. Some patients may experience dizziness, light-headedness,
nausea or sweatingthese symptoms are called needle shock which are caused by the
patient being anxious, nervous, fatigued, having an empty stomach or hypo- or
hypertension. There symptoms are not life threatening. Upon removal of the needles,
symptoms will immediately go away. To prevent needle shock, avoid having an empty
stomach before treatment, relax, and advise the acupuncturist of any medical condition.
Date:

_______________________________

Signature:

_________________________________________