Kula Yoga and Bodywork Acupuncture Intake

Important: Our clinic values the importance of a patient’s right to healthcare confidentiality and therefore takes our custodianship of your health record very seriously. This questionnaire/intake form is completely confidential. To help our clinic provide you with the best care, please fill it out as completely as possible, even if you do not feel certain questions pertain to your present condition. All the information you provide is relevant to a holistic healthcare understanding. Thank you for providing as much information as you are comfortable disclosing.

First name

Last name

Preferred name

Birthday

Month

Day

Year

Sex

Male

Female

Other

Ethnicity

Place of Birth

Phone

Email

Address

Primary Care Physician

Primary Care Physician Number

Emergency Contact

Emergency Contact Number

Have you had Acupuncture before?

Yes

No

If yes, with whom? For what condition? Was it beneficial?

How did you hear about us?

Please tell us: Your main Complaint. How long has this affected your life? What makes it better? Worse? How does the condition interfere with your daily activities?

Level of Severity 1-10

Please list all known allergies