Stittsville New Patient Acupuncture Forms

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Oaktree New Patient Acupuncture Forms

Acupuncture History

Have you ever been to an acupuncturist before?*

Yes No

Name of Acupuncturist and City

Approximate date of last visit:

Duration and frequency of care:

If applicable, is there anything about your past acupuncture experience that you would like to tell me, positive or negative?

Major Health Complaints

1)*

2)*

Medical History

Do you take any supplements? If so, for what purpose? Please include the brand and dosage, if known.

Example: Omega 3, Vitamin B, Probiotics, Vitamin D, Multivitamin, Iron

Do you have any allergies and/or sensitivities that you feel we need to be aware of in order to treat you safely (e.g. latex allergy, metal allergy, severe peanut allergy, etc.)?

How would you describe your diet? What do you think you do well and which areas do you feel could do with the most improvement?

Medications - Name and for which condition(s)

Family Health History - What significant health concerns have your family members experienced?*

Surgeries - Please list and for what condition(s) (include year performed)*

Other health problems, concerns, or additional information:

Oaktree New Patient Acupuncture Forms

Patient Information

Acupuncture History

Major Health Complaints

Medical History