NAME* TODAY'S DATE*
STREET* BIRTHDATE*
CITY, STATE, ZIP* SEX*
PHONE: HOME HEIGHT WEIGHT
WORK EMAIL*
CELL REFERRED BY
Major Complaint: *Required field
Other Complaints:
Date of Onset of Major Complaint:
Pain is:
Have you had this in the past? When?
What makes it better? What makes it worse?
Is your condition:
Medications/Drugs/Herbs/Supplements you are taking:
Surgeries/Operations you have had and dates:
Date of your last physical exam By whom?
MEDICAL HISTORY: Do you have or have you ever had: Other:
FAMILY HISTORY: Has any member of your family had any of the above?
If yes, which member and what did they have?
ENERGY LEVEL: Time of day: Time of day:
STRESS: What causes it?
SWEATING:
CIRCULATION: Feelings of
Other:
SKIN:
SLEEP:
Other sleep problems: How many hours per night?
HEAD:
Other:
EYES: Other:
EARS:
Other:
NOSE: Other:
THROAT:
Other:
CHEST:
Sputum color: Consistency: Other:
BLOOD PRESSURE:
BOWELS:
Number of bowel movements per day: Other:
URINE: Color: Frequent urination? Number of times:
Other:
MUSCULOSKELETAL: Pain in:
Other:
Other:
NEUROLOGICAL:
Other:
FEMALES: Pregnant? Last monthly period: Last PAP test: Form of birth control: Other:
Age started menstrual cycle: Age stopped:
Color: Other:
MALES:
Other:
APPETITE:
Specific food cravings? If yes, what?
DIGESTION:
How long after eating?
Food allergies? If yes, to what?
NUTRITION: List some of your favorite foods Do you?
How many meals do you eat? When is your biggest meal?
Do you eat when worried or rushed?
How many glasses of water do you drink per day?
LIFESTYLE: Currently use?
Regular exercise?
If yes, what type? Frequency
New Patient Intake Form
Where?
Other:
AcuTherapy Healing Center
9420 S.W. 77th Avenue
Suite 201
Miami, FL 33156
(305) 725-6269
Patricia Kinsley, A.P., Dipl. O.M.
www.AcuTherapyCenter.com
