Shamrock Acupuncture Round Rock
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New Patient Intake
New Patient Intake Form
First Name
Last 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?
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:
Checkbox Field
Poor Sleep
High Stress
Anxiety/Depression
Digestive Issues
High Blood Pressure
Diabetes
Heart Disease
Stroke
Cancer
Respiratory Issues
Pregnancy
Other
None
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 Company (Optional)
Insurance ID Number (Optional)
Insurance Group Number (Optional)
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