Intake form

New Leaf Acupuncture Clinic - New Patient Questionnaire
The following information is helpful to the diagnostic procedure and enables us to provide you with better treatment.
Name ____________________________ ! Female ! Male Birth Date ___________ Today’s Date __________
Address_____________________________________________________________________________________________
E-mail address ____________________________________________________Phone_____________________________
Marital Status __________________ No. of Children ________ Occupation_____________________________________
Emergency Contact Name _______________________________________ Phone _______________________________
Doctor_______________________________________________________________________________________________
Is this your first time getting acupuncture? !Yes ! No. How did you hear about us?________________________

Goals: What would you most like to achieve with acupuncture treatments?
_____________________________________________________________________________________________________
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Major Symptoms: Please list in order of importance what symptoms are of concern to you.
(most concerning to least, along with the duration of the symptom)
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Experiencing pain/discomfort in any area of your body? !Yes !No

Please rate your pain level: < 1 2 3 4 5 6 7 8 9 10 >
Duration of pain: ____________
Use the illustration to indicate painful or distressed areas.
Indicate the location of the discomfort by using the symbol that
best describes the feeling:
X X X Sharp/Stabbing P P P Pins & Needles
D D D Dull/Aching N N N Numbness
T T T Tightness/Spasms
Aggravating factors: (eg. Heat) ____________________Alleviating factors: (eg. Cold) ______________________
Medical History
Do you or have you had any of the following conditions? If yes, please indicate date of diagnosis.
Date Diagnosed
Date Diagnosed
Cancer (type) ____________________________________ Hepatitis _____________________________________ HIV _____________________________________________ Stroke _______________________________________ Diabetes ________________________________________ High Blood Pressure __________________________ Mental Illness ____________________________________ Thyroid Disease ______________________________ Heart Disease ____________________________________ High Cholesterol ______________________________ Seizures _________________________________________ Other ________________________________________ Please list any surgeries or major injuries with dates.
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List any medications or supplements you have taken in the last 2 months.
_____________________________________________________________________________________________________
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Do you have a pacemaker or any metal devices in your body? !Yes ! No. If so, which: ____________________
Intolerant of, or allergic to: ! Alcohol Swabs ! Iodine ! Arnica Cream ! Bio Oil

Family History
Indicate close family members with any of the following:

Family member(s)
Family Member(s)
Cancer (specify type) _____________________________ Heart Disease ________________________________ High Cholesterol _________________________________ Stroke _______________________________________ Diabetes ________________________________________ High Blood Pressure __________________________ Mental Illness ___________________________________ Alcoholism ___________________________________

Lifestyle Habits

Do you have an exercise routine? !Yes ! No
Please describe ______________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
How many hours per night do you sleep on average? __________ Do you wake rested? !Yes ! No
Nicotine Use: __________________ Alcohol Use (#drinks/week and type):____________________________________
Caffeine Use (#drinks/day and type): ____________________Water intake (how much/day): ____________________
Briefly describe your dietary habits (#meals/day; type of food; snacks; sweet tooth)
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Energy: How is your energy?
Please circle. Low < 1 2 3 4 5 6 7 8 9 10 > High
What time of day is your energy:
Highest: !6am-12pm !1pm-5pm !6pm-12am Lowest: !6am-12pm !1pm-5pm !6pm-12am
Do you fatigue easily? !Yes ! No
How do you feel emotionally?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Emotions: How are your stress levels?
Please circle. Low < 1 2 3 4 5 6 7 8 9 10 > High Do you have: ! Panic attacks ! Depression ! Anxiety/Worry ! Irritability ! Nervousness ! Fear attacks ! Mood Swings ! Difficulty Making Decisions ! Poor memory ! Difficult concentration ! Suppressing Emotions ! Frequent Sighing ! Easily Startled Bowel movements:
Urination:
How often?___time(s) a day, or __ time(s) a week Please tick symptoms you have or
have had in the past year:
Respiratory/Cardiovascular
Energy and Immunity
! Heart Palpitations / Fluttering ! Poor Circulation (Cold hands/feet) Male Health
! Particularly sensitive to the cold Head, Eye, Ear, Nose, and Throat
Musculoskeletal
Gastrointestinal
! Finger Pain / Tingling / Numbness Neurological
Kidney/Urinary
! Frequent Urinary Tract Infections ! Dry / Itchy Skin ! Brittle Nails Women Only:

Currently Pregnant? !Yes ! No ! Vaginal discharge. Colour?_____ Female Health
. . . ! before ! during ! after Acupuncture Appointments

Please bring this completed new patient questionnaire with you to your first appointment.
Please bring or wear loose clothing (shorts, t-shirts) to each appointment.
Please eat a light meal or snack before your appointment; an empty stomach may cause dizziness.
Please do not eat or drink food that may change the color of your tongue or brush your tongue the day
of your appointment. (coffee, fizzy drinks, juice, liquorice, beetroot, etc)
While contra-indications for acupuncture are rare and, although also rare, sometimes a small local
bruise can occur.

What to expect at your first visit?

Your first visit will take a little over one hour and will include an acupuncture treatment. We will discuss
your health questionnaire and any concerns you have prior to the treatment. I will make a diagnosis, a
treatment plan and may give a few suggestions regarding your condition. If you have any questions
please do not hesitate to email or call me at:
[email protected]
(087) 2632732
Niall O’Leary
New Leaf Acupuncture Clinics:
212 Kimmage Road Lower, Dublin 6w
50 Marian Road, Rathfarnham, Dublin 14
15 Grantham St, Portobello, Dublin 8

Financial Policy, etc

Payment is due at time of service for all patients. A fee will be charged for missed appointments or
cancellations without a 24-hour notification.
I also understand that these treatments may produce some bruising and I release the practitioner from
liability in the event that that should occur.
________________________________________ ____________________
Signature
________________________________________ Please Print Name

Source: http://newleafacupuncture.ie/wp-content/uploads/Intake-Form2.pdf