Alexis Arvidson Acupuncture

Name*

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Occupation*

Date of Birth*

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Referred By*

Emergency Contact*

Emergency Contact Phone Number*

Primary Care Physician:*

May we contact your physician?*

Yes
No

What brings you to acupuncture at this time?*

Please provide your current state of health. *

Please describe your personal and family health history. *

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 experience with detoxing and cleansing? Please describe.*

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?

Please continue on to the next four questions if you have a menstrual cycle.

How long is your cycle? (from the first day of bleeding until the day before your next bleeding)

How many days do you bleed?

What is the quality and quantity of the blood? (color, amount, clotting etc.)

Do you have regular cycle symptoms such as; PMS, breast tenderness, exhaustion, food cravings, headaches?

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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