Alexis Arvidson Acupuncture

Name*

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Occupation*

Date of Birth*

MM

DD

YYYY

Place of Birth

Time of Birth

Referred By*

Emergency Contact*

Primary Care Physician:*

Emergency Contact Phone Number*

May we contact your physician?*

Yes
No

Please provide your current state of health. *

Please describe your personal and family health history. *

What brings you to acupuncture at this time?*

What is the quality of your sleep?*

What time do you go to sleep and wake up each day?*

Do you wake to use the bathroom during the night?*

Yes
No

How do you feel when you wake up?*

How is your appetite?*

Please list the foods you commonly eat and the times you take each meal.*

(Please include, Breakfast, Lunch, Dinner, Snacks & Drinks)

What is your daily water intake?*

How is your digestion?*

Do you experience one or more bowel movements per day?*

Do you experience gas, bloating, acid reflux or frequent burping?*

Do you have chronic pain? Please describe.*

How is your mood in general?*

How would your friends and family describe you?*

Do you feel your life has purpose?*

Do you have meaningful relationships?*

If you could change one thing in your life that would increase your vitality, what would it be?

(The next five questions are for Female clients exclusively)

How many days is your cycle?

Do you have PMS?

Do you have breast tenderness?

Do you experience blood clots when you bleed?

How long does your bleeding last?

Thank you for your time and your honesty. These reflections will help the success of our work together.

Acknowledgements*

I acknowledge that I have received the NOTICE OF PRIVACY PRACTICES of this practice.
I acknowledge that I have been advised to consult a physician regarding my health concerns.
I acknowledge and agree to the fees and insurance coverage policies of this practice.
I acknowledge and agree to the nature of treatment of this practice
I acknowledge and agree to the purpose of treatment of this practice
I understand that Chinese medicine procedures have been shown to be safe and effective.
I acknowledge and agree to the missed appointment/late cancellation policy of this practice.
I authorize the insurance company to make payment to this practitioner for my treatments and services. I authorize the release of information concerning my (or my child’s) healthcare advice and treatment provided only for the purpose of evaluating and administering claims for insurance benefit.

Please make sure all acknowledgements have been made before proceeding.

Missed Appointements or Late Cancellations*

I acknowledge and agree to the missed appointment/late cancellation policy of this practice.

The fee for a missed appointment or cancellation with less than 48 hours notice is $170.

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Alexis Arvidson Acupuncture

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