New Patient Intake

Please complete this form before your first appointment so we can prepare for your visit.

Fields marked * are required.

About You

Full Name *

Date of Birth *

Email *

Phone *

Address *

Gender *

Male Female

Emergency Contact *

Emergency Contact Phone *

Have you had acupuncture before? *

Yes No

How did you hear about us? *

Your Health

Please list your chief complaints: *

I have been evaluated by a physician, or chiropractor, or dentist for the condition being treated within 12 months before the acupuncture was performed. *

Yes No

I am seeking acupuncture treatment for smoking addiction, weight loss, alcoholism, chronic pain, or substance abuse. I understand that if no substantial improvement is observed after 20 acupuncture sessions or two months of treatment (whichever occurs first), I will be advised to consult a physician. *

Yes No

Please list your prescription or supplements:

Please list any surgeries you have had:

Please list any medical devices you have (e.g. Pacemaker, medical implants):

Please list any allergies you have:

Do you smoke, drink alcohol, or use any recreational drugs? *

What aspects of your daily life are most affected by your health issue? Are there any activities you used to enjoy but can no longer do or find more difficult now? *

Insurance (Optional)

Insurance Company

Insurance ID Number

Insurance Group Number

Your answers go directly to Shamrock Acupuncture and are used only to prepare for your care. Questions? Call 512-270-0393.