NEW PATIENT INTAKE FORM

Upon successful completion, you will be directed to our online bookings form to book your first appointment.

All information will be stored securely to ensure your privacy and is 100% confidential

Personal Details

Name(Required)

First Last

Age(Required)

Date of Birth(Required)

Gender(Required)

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Phone (Mobile)(Required)

Phone (Day)

Phone (Night)

Email(Required)

Occupation

Who is your primary heath care provider/MD?(Required)

Emergency Contact(Required)

Emergency Contact Phone(Required)

Main Complaints

Please identify your FIRST major health concern(Required)

How long have you had this problem?(Required)

Please identify your SECOND major health concern (if any)

How long have you had this problem?

Please identify any other health concerns (if any)

How long have you had this problem?

Have you been given a diagnosis for these problems by a GP or Specialist?(Required)

YES

What other treatments have you tried and what were the outcomes?

Personal Medical History

(Please include your childhood history)

Illnesses

Surgeries

Significant Trauma

i.e. motor vehicle accidents, fractures, etc.

Do have a history of current or past infectious disease?

Please describe

Medicines

Please list all medications, herbs, vitamins and over the counter drugs.

Allergies/Sensitivities

Please list any foods, drugs, medications or environmental factors which you are sensitive or allergic to.

Declaration

I understand that in all forms of health care there may be some very slight risks as a result of acupuncture treatment.

These may be:

Not uncommon – itchiness at needle insertion site, minor bleeding, dull achy feeling possibly lasting up to 2-3 days.
Occasionally – temporary exacerbation and/or aggravation of symptoms.
Rare – Pneumothorax, nerve pain, punctured organs, hematoma and needle shock.

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