Patient Information Form - Uptown Acupuncture

Patient Information

Are you a first time patient?*

Yes
No

If you are a first time patient, we will ask a Family Medical History.

If you are a current patient but your medical history has changed since your last visit, please choose "Yes" here.

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Have you had Herbal Medicine?

Yes
No

Are you under the care of a physician now?

Yes
No

For what?*

Other concurrent therapies?

Pharmaceuticals taken in the past 2 months?

Other supplements taken in the past 2 months?

Issue #1

Date Symptoms Began

Briefly Describe Symptoms

How did your symptoms begin?

Average Pain Intensity

Last 24 Hours

Average Pain Intensity

Last Week

Is it getting worse?

Yes
No

Does it bother you at....

Sleep
Work
Other

What seems to make it better?

What seems to make it worse?

I Have Another Medical Issue

Issue #2

Date Symptoms Began

Briefly Describe Symptoms

How did your symptoms begin?

Average Pain Intensity

Last 24 Hours

Average Pain Intensity

Last Week

Is it getting worse?

Yes
No

Does it bother you at....

Sleep
Work
Other

What seems to make it better?

What seems to make it worse?

Family Medical History

Allergies?

Cancer?

Additional Medical Issues

Check any of the following conditions you currently have, or have had in the past. (Please also check if you feel any of the following are a significant part of your medical history).

Other

Please Specify

Lifestyle

How often do you experience each of the following items?

General Symptoms

	Not Often	Occasionally	Moderately	Somewhat Often	Frequently
Poor Appetite
Bodily Heaviness
Chills
Bleed or Bruise Easily
Heavy Appetite
Heavy Sleep
Cold Hands & Feet
Night Sweats
Sweat Easily
Strongly like cold drinks
Strongly like hot drinks
Strong Dreams / Disturbed Sleep
Poor Circulation
Fatigue
Shortness of breath
Muscle cramps
Recent weight loss / gain
Lack of strength
Fever
Vertigo or dizziness
Particular Taste

How often do you experience each of the following items?

Particular Tastes*

Pain Scale

Please describe the level of pain you are experiencing.

Final Questions

In general, would you say your overall health right now is...

Signature

CAPTCHA

Email

This field is for validation purposes and should be left unchanged.

	Not Often	Occasionally	Moderately	Somewhat Often	Frequently
Alcohol
Tobacco
Marijuana
Other Drugs
Stress
Occupational Hazards