1. PERSONAL HISTORY
Name ______________________________________ Address______________________________________________
City ________________________________________ State/Prov ___________Zip/Postal Code____________________
Home Phone _________________________________ Birth Date ______________Age _____ Sex: M F
Social Security # ______________________________ Circle one: Married Single Widowed Divorced Separated
Business Employer ____________________________ Type of Work_________________________________________
Business Phone _______________________________ Name of Spouse_______________________________________
Name and Ages of Children___________________________________________________________________________
Referred to This Office By ______________________ Name and Number of Emergency Contact___________________
address _____________________________________________________________________________________
Insurance Plan Name or Program Name__________________________________________________________________
Insured Name, DOB and ID#__________________________________________________________________________
_______________________________________________________________________________________
CURRENT HEALTH CONDITION
Main Complaint_____________________________________________________________________________________
Doctors Seen For This Condition _______________________________________________________________________
Type of Treatment _____________________________ Results______________________________________________
When Did This Condition Begin?__________________ Date of Accident _______________________________________
Is This Condition: Job Related Auto Accident Home Injury Fall Other_____________________________
Brief Description of Accident___________________________________________________________________________
__________________________________________________________________________________________________
Drugs You Now Take: Pain Killers/Muscle Relaxers Nerve Pills Blood Pressure Medicine Insulin
Other_________________________________________________________________________
Do You Suffer From Any Condition Other Than That Which You Are Now Consulting US?____________________________
________________________________________________________________________________________
PAST HEALTH HISTORY
Major Surgery/Operation: Appendectomy Tonsillectomy Gall Bladder Hernia Back Surgery
Broken Bones Other ____________________________________________________
Hospitalization (Other Than Above) _____________________________________________________________________
Previous Acupuncture Care: Yes No Doctor’s Name ______________________________________
Condition for Acupuncture _______________________ Acupuncture Results _________________________________ _