Acupuncture Intake Form

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Acupuncture Intake Form

The Acupuncture Intake Form is to be completed BEFORE your Initial Acupuncture Appointment! You must have an Acupuncture Appointment already scheduled with our office to fill out this intake form!

"*" indicates required fields

Patient Information :

Name :*
Gender :*
Address :*

Emergency Contact :*

Have you ever had Acupuncture before?*
Have you visited a medical doctor for this condition?*

Medical History

Please list any current medications (prescription and over the counter), vitamins, supplements, herbs or homeopathic remedies that you are taking, including dosage :
Are you Pregnant?
Do you have a contagious disease at this time?*
Past Medical History :*
Check any of the following conditions you currently have or have had in the past. Please also check if you feel any of the following are a significant part of your medical history.
Please List All
Please List All

Lifestyle :

Lifestyle :
Type of Exercise(s) and How often do you exercise?
Consent
This field is for validation purposes and should be left unchanged.

 West Side Chiropractic

2732 Mt. Vernon Ave

Evansville, IN 47712

(812) 425-5686