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How did you hear about our office?
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Have you had acupuncture before?
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Have you had Cupping before?
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Reason for today’s visit
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Prior treatment? If so, list specialist/diagnosis given?
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Onset of current complaint(s):
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Current level of pain
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Please circle all areas of concern
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Current Height/Weight?
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My condition is...
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My complaint is currently aggravated by
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My current complaint is made better with
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Diagnosing physician
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List all medications currently taken
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Reason for medication
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List any herbs you are taking
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List supplements you are taking
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Family medical history
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List surgeries and date
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Please select all that apply to you
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Accident/traumas with date
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Prior imaging studies (MRI/XRAY) and when?
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Please any other pertinent information here:
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Medical History
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General Symptoms
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Musculoskeletal
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Eyes
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Head, Ears, Nose, Mouth ,Throat
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Cardiovascular
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Cardiovascular Continued
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Respiratory
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Skin and Hair
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Gastrointestinal
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Frequency of Bowel Movements
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Urinary and Genital
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How often you urinate at night
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Urinate in 24 hours
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Sleep
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Average number of hours I sleep per night
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Emotional
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Pregnancy and Gynecology
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List any other Pregnancy/Gynecological Problem
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Date of last menses
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Date of last pap test
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Method of birth control
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Please list any other emotional, mental or physical trauma
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