Shamrock Acupuncture Round Rock
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New Patient Intake
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Name
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First
Last
Date of Birth
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Email
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Phone
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Address
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Gender
*
Male
Female
Emergency Contact
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Emergency Contact Phone
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How did you hear about us?
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Have you had acupuncture before?
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Yes
No
Please list your chief complaints:
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I have been evaluated by a physician, or chiropractor, or dentist for the condition being treated within 12 months before the acupuncture was performed.
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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.
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Yes
No
Are you using prescription or herbal medicines?
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Yes
No
If yes, please list:
Have you ever had surgery?
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Yes
No
If yes, please explain:
Do you have medical devices? (e.g. Pacemaker, medical implants)?
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Yes
No
your explain: had
If yes, please explain:
Do you have allergies?
*
Yes
No
If yes, please list:
Do you have any of the following conditions? (Check all that apply)
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Heart Disease
High Blood Pressure
Diabetes
Stroke
Cancer
Respiratory Issues
Seizures
Anxiety/Depression
Digestive Issues
Pregnancy
Blood Disorders
Other
None
What is your sleep quality? If 10/10 is the best.
Selected Value:
0
Do you experience chronic stress? 0/10 means no stress at all.
Selected Value:
0
Do you smoke, drink alcohol, or use any recreational drugs?
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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?
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On a scale from 0 to 10, where 10 means you have the best possible quality of life with no limitations, where would you rate yourself right now?
Selected Value:
0
Insurance Company (Optional)
Insurance ID Number (Optional)
Insurance Group Number (Optional)
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