Golden Valley Acupunture Center

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General Intake Form

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Home Address
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City
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Home Phone
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Work Phone
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E-mail
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Birthdate
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If under 18, person responsible for your account
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Emergency Contact

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Contact Phone
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Occupation
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Gender
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Height
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Weight
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Whom should we thank for referring you to our office?
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Have you had acupuncture therapy before?
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With Whom?
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Please indicate any significant illnesses you or a blood relative (grandparent, parent, or sibling) have had:

(marking “yes” does not make you ineligible for treatment, however, it may restrict some treatment modalities):

Cancer
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Hepatitis
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High Blood Pressure
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Rheumatic Fever
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Infectious Diseases
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Diabetes
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Heart Disease
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Seizures
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Emotional Disorder
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Tuberculosis
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Sexually Transmitted Diseases
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Dates
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Other Conditions
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Dates
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List any medications and supplements you are currently taking: (Continue on back if necessary)

Medicine
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Dosage
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Reason
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How Long
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Prescribed by
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Date of Last Checkup
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Please indicate the use and frequency of the following:

Coffee/Black Tea
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How Much
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Soda Pop
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How Much
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Recreational Drugs
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How Much
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Tobacco
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How Much
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Alcohol
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How Much
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Water Intake
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How Much
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Age of first period (menarche)
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Are you pregnant
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# of pregnancies
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Age of last period (menopause)
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# of live births:
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# of abortions:
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# of miscarriages:
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Number of days between periods
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Date of last: OB/GYN exam:
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PAP Smear:
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Number of days of flow
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Mammogram
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Bone Density Scan:
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Color of flow
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Results
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Clots?
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Color
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# of pads you use per day:
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1 st day
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2 ND day
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3 RD day
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4 th day
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+days
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Have you been diagnosed with:

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Location of pain:

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Nature of pain: (Please indicate before, during, or after menses)

Cramping
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Stabbing
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Burning
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Aching
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Dull
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Bloating
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Consistent
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Intermittent
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Bearing Down Sensation
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Other symptoms related to menses:
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Have you ever been diagnosed with:
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Date of last prostate check up
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PSA Results
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Manual Prostate exam results
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Lab Results:
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Frequency of urination: daytime
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Nighttime
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Color of urine
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Odor
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Symptoms related to prostate:

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Other
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Date of last prostate check up
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PSA Results
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Manual Prostate exam results
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Lab Results:
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The following is a list of symptoms that you may or may not ever experience.

lack of appetite
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skin problems
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excessive appetite
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feeling of claustrophobia
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loose stool or diarrhea
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bronchitis
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poor digestion/indigestion/vomiting
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colitis or diverticulitis
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belching, burping
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constipation
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heartburn/reflux
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hemorrhoids
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skin problems
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feeling of claustrophobia
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feeling food retention in the stomach
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recent use of antibiotics
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tendency to become obsessive
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eye problems
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insomnia, difficulty sleeping
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jaundice (yellowish eyes or skin)
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heart palpitations
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difficulty digesting oily foods
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cold hands and feet
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gall stones
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nightmares
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light colored stool
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mentally restless
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laughing for no apparent reason
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angina pains
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abdominal pain
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chest pain
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sciatic pain
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headaches
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pain or coldness in the genital area
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cough
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shortness of breath
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decreased sense of smell
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nasal problems
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skin problems
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bronchitis
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soft or brittle nails
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easily angered or agitated
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difficulty in making plans/decisions
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spasms or twitching of muscles
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low back pain
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knee problems
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hearing impairment
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ears ringing
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kidney stones
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decreased sex drive
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hair loss
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urinary problems
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fatigue
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edema
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blood in stool
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black tarry stool
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easily bruised
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difficulty in stopping bleeding
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asthma
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tendency to catch colds easily
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intolerance to weather changes
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allergies
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hay fever
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dizziness
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tendency to faint easily
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high cholesterol levels
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sudden weight loss
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How do you FEEL about the following areas of your life? Please check the appropriate boxes and indicate any problems you may be experiencing.

Significant Other
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Your Comments...
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Family
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Your Comments...
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Diet
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Your Comments...
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Sex
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Your Comments...
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Self
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Your Comments...
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Work
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Your Comments...
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Exercise
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Your Comments...
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Spirituality
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Your Comments...
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What are the main health problems for which you are seeking treatment?
Main health problems...
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How long have you had this condition?
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What other forms of treatment have you sought?
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What helps your condition?
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What aggravates your condition?
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List any other health problems you now have.
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List any allergies, food sensitivities or food cravings that you have
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Please list any accidents, surgeries, hospitalizations or other major health incidents in your life, including dates:
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Upload your documents...
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In order to maintain the integrity of our practice, Golden Valley Acupuncture Center must request that all cancellations be made prior to within 24 hours of your appointment. Failure to provide at least a 24 hour notice or failure to show for an appointment will result in your account being charged for the full price of the visit.*

THANK YOU FOR YOUR UNDERSTANDING.

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*We do understand that unforeseen circumstances arise, and for that we will not charge you the first time this situation occurs.

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