Intake form

Medical History

This Information is essential for the diagnosis procedure and helps us to provide you with a better treatment. Please fill out as accurately as you can.

You can adjust the size of the text window of some fields. There's no limit of the amount of the text you typed in.

THIS INFORMATION IS CONFIDENTIAL

Your Name (required)

Your Email (required)

Your Social Security Number

Your Health insurer:

Your Health insurer Relationship number:

Your Care pack:

Your phone number(s)

Your address/residence

Name/Adres/Residence of your family doctor

Birth date: Height: Weight:

What is your principle complaint?

What has been diagnosed (By M,D.)?

Any problems during your birth?

Vaccination history. Any reactions that you remember?

Any unusual vaccinations?

Childhood Illnesses? Any surgery or accidents?

Age:

Age:

Age:

What kind of adolescence Illnesses did you have? Are there any surgery or accidents?

Age:

Age:

Age:

What about adulthood illnesses? Are there any surgery and/or accidents?

Age:

Age:

Age:

Age:

Age:

Please note all major illnesses in your immediate family, like diabetes, heart disease, blood pressure, neurological disorders, psychological disorders, blood disorders, orthopedic disorders etc.

Are you taking any medication? Please note all medication, herbs, vitamins, and minerals you take even if you take them only occasionally.

Do you have any scars? Note location of all operation or injury scars (even minor ones).

SYMPTOM LIST

Check any problem, disease, or symptom you have now. Mark items that affected you in the past.

Skin:

Heart and vascular:

Gastrointestinal:

Respiratory:

Hormonal imbalance:

Other hormone imbalance:

Male:

Female:

Autoimmune and inflammatory conditions:

Effects of focal infections:

Connective tissue or ligament diseases:

Ear, nose & throat:

Oral diseases:

General:

Before noon time:

Medication and drugs:

Please drop here your complete life story as detailed as possible. Especially the ones according to you that are responsible for your complaint:

For cosmetic acupuncture please specify oversensitivity or allergy for cremes and other fluids:

Attachment(s) (for cosmetic acupuncture please provide detailed photos of your face)

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