Professional Documents
Culture Documents
Name: ___________________________
Phone #: _________________________
Address: _________________________________________________________________
Complaint: _______________________________________________________________
Referred by: ______________________________________________________________
Medical History:
Have you ever had:
Yes No
Sinusitis
Hay Fever
Heart Attack
Chest Pain
Asthmatic Wheezing
Indigestion
Painful Joints
Back Pains
Anxiety/Stress/Emotional Problems
Neck Pains
Headaches
High Blood Pressure
Nervousness
Pregnant
Medications/Operations (Please list all performed and your age when each was performed):
_________________________________________________________________________
_________________________________________________________________________
X-Rays: __________________________________________________________________
Treatment (Radiation, PT/OT, Chemotherapy and Psychotherapy etc.)
_________________________________________________________________________
_________________________________________________________________________
I understand that the acupuncture treatments are safe. All needles are made with surgical
steel, are sterile and only disposable needles are used. There is no medication in the
needles.
I understand that during acupuncture treatments, there will be a feeling of slight pain
when the needle punctures the skin. Sometimes there may be slight bleeding at the points
where needles are removed. Some patients may experience dizziness, light-headedness,
nausea or sweatingthese symptoms are called needle shock which are caused by the
patient being anxious, nervous, fatigued, having an empty stomach or hypo- or
hypertension. There symptoms are not life threatening. Upon removal of the needles,
symptoms will immediately go away. To prevent needle shock, avoid having an empty
stomach before treatment, relax, and advise the acupuncturist of any medical condition.
Date:
_______________________________
Signature:
_________________________________________