CLIENT INTAKE

Name *

First

Last

Date of Birth (mm/dd/yyyy) *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Gender *

Male Female

Emergency Contact *

Contact Phone Number *

What health concerns do you currently have? *

Overall are your symptoms: *

Improving Remaining the same Worsening

When and how did your symptoms begin? *

Please check any of the following conditions that apply to you today: *

Headache Rash or Hives Diarrhea or Vomiting Headache Cuts, Bruises, Abrasions or Sunburn Undiagnosed lumps, bumps or pain Suffering from fever, or contagious or infections disease Consumed Alcohol, Recreational drugs or heavy metal Broken bones in the last 3 months

(If you checked any of the above boxes, today's treatment may have to be modified to avoid certain areas of your body)

Notes to Therapist: *

Do you exercise? *

Yes No

If yes, what kind and how often? *

Do you follow a special diet? *

Yes No

Daily water intake (per day): *

Do you used tobacco? *

Yes No

If yes, how many packs a day? *

Do you drink alcohol? *

Yes No

If yes, how often do you drink? *

Acupuncture should not be construed as a substitute for medical examination, diagnosis, or treatment of an illness. I take responsibility for consulting with my physician for an ailment or condition of concern to me. *

I agree

I have been informed that acupuncture is a safe method of treatment, but that it may have side effects, including bruising, numbness or tingling near the needling sites that may last a few days, with possible dizziness or fainting. Bruising is common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Iunderstand that the risk of infection is negligible when all needles are sterile. *

I Agree

In a professional, therapeutic relationship, inappropriate words or advances by or between therapist or client is never appropriate and may terminate acupuncture therapeutic relationship. *

I Agree

I understand draping will always be used; preferred method is to be covered at all times, meaning only the body part being treated will be exposed (no exceptions). Your modesty will be honored at all times. *

I Agree

I acknowledge that if I am unable to keep a scheduled appointment, 24 hours' notice is required or I may be charged for the time reserved. *

I Agree

Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage. *

I Agree

If I experience any pain or discomfort during the acupuncture session, I will immediately communicate that to the therapist so that treatment can be adjusted accordingly. *

I Agree

Both the acupuncturist and I have the right to terminate the acupuncture session and or therapeutic relationship at any time for any reason. *

I Agree

I have read and understood this consent form in its entirety and I have had the opportunity to question the contents and my therapy treatment. If at any time there are changes in the information given, or in my condition, I will notify the therapist and update this form before receiving additional massage. I have stated all of my known medical conditions and have answered all questions honestly on the intake form. I have read the above noted consent. *

I Agree

Client Intake