CONFIDENTIAL PATIENT INFORMATION Full Name: Date: Address: Home Phone: Work Phone: Cell Phone: Email Address: Age: Date of Birth: No Pregnant? □ Yes □ # of Children: Spouse/Guardian Name: Marital Status: M S W D Name: Employer’s Occupation: Phone Number: Emergency Contact Person: Relationship: Phone Number: *Acupuncture will only be billed through insurance if you have a Blue Cross Blue Shield federal policy* __________________________________________________ Who may we thank for referring you? (Relative, Friend, Yellow-Book, Online Search) Have you had previous Acupuncture Care? Yes 􀂉 No 􀂉 ____________________________________________________ Approximate date of your last visit? Addressing What Brought You Into This Office: Health Concerns: Rate of Severity When did this Have you Did it begin % of the (Please list by severity) episode start? had this slowly, time your 1 = Mild condition immediately, pain is (Days, weeks, 10 = Worst months or years Imaginable before? or with an present ago?) When? injury? 1. 2. 3. 4. 5. In General, What Symptoms Do You Experience: Pain Muscle Spasm Stiffness 􀂉 􀂉 􀂉 Numbness Headache Tingling 􀂉 􀂉 􀂉 Swelling Tightness Weakness 􀂉 􀂉 􀂉 Quality of Your Symptoms: Sharp Throbbing Burning 􀂉 􀂉 􀂉
CONFIDENTIAL PATIENT INFORMATION Full Name: Date: Address: Home Phone: Work Phone: Cell Phone: Email Address: Date of Birth: Age: # of Children: Pregnant? □ Yes □ No Marital Status: M S W D Spouse/Guardian Name: Occupation: Employer’s Name: Phone Number: Emergency Contact Person: Relationship: Phone Number: *Acupuncture will only be billed through insurance if you have a Blue Cross Blue Shield federal policy* Who may we thank for referring you? __________________________________________________ (Relative, Friend, Yellow-Book, Online Search) Have you had previous Acupuncture Care? 􀂉 Yes 􀂉 No Approximate date of your last visit? ____________________________________________________ Addressing What Brought You Into This Office: Health Concerns: (Please list by severity) Rate of Severity 1 = Mild 10 = Worst Imaginable When did this episode start? (Days, weeks, months or years ago?) Have you had this condition before? When? Did it begin slowly, immediately, or with an injury? % of the time your pain is present 1. 2. 3. 4. 5. In General, What Symptoms Do You Experience: 􀂉 Pain 􀂉 Muscle Spasm 􀂉 Stiffness 􀂉 Numbness 􀂉 Headache 􀂉 Tingling 􀂉 Swelling 􀂉 Tightness 􀂉 Weakness Quality of Your Symptoms: 􀂉 Sharp 􀂉 Throbbing 􀂉 Burning