New Patient Forms

Please fill out both forms below prior to your first appointment.

Protected Health Information

First Name *

Last Name *

Primary Phone Number *

Secondary Phone Number (optional)

Street Address *

City/State/Zip *

Your Email *

Birth Date *

Age *

Marital Status

Married

Single

Occupation *

Emergency Contact Name *

Emergency Contact Number *

Physician *

Physician Phone Number *

Whom may we thank for referring you?

What are your health goals (they can be emotional, physical, spiritual or mental)?

If you can see one change in your life over the next 3 months working together, what would it be?

What is the main reason you are seeking treatment? *

Have you been treated by Chinese medicine for this condition before?

Yes

If yes, when?

Describe any other treatment you've had for this condition

Have you received a diagnosis for this condition? *

Are you currently taking medications for this condition?

Yes

If yes, describe medication, date started, and dosage.

Describe procedures you've had for this condition *

Brief history of your condition from onset to the present *

Any other conditions you would like to address with Chinese medicine

Hospitalizations

Female patients only

Do you exercise? *

Yes

How many times/week? How many hours at a time?

Get enough sleep? *

Yes

How many hours/night?

Have a stressful job? *

Yes

How many hours do you work?

Smoke tobacco? *

Yes

How many per day? How long?

Drink caffeine? *

Yes

What kind? How much?

Drink alcohol? *

Yes

How many per day? Per week?

Other recreational drugs?

Please describe what you typically eat

Breakfast

Lunch

Dinner

Snacks

Eat regular meals?

I prefer

Hot/cooked food

Cold/raw food

How much water do you drink per day?

Please choose 1 or 2 emotions that seem predominant in your life - frequently experienced, difficult to express, or in in some way influential (example: fear, anger sadness, joy, excitement, anxiety, worry, etc)

Please list recreation, hobbies, or pleasure activities and how often you engage in them

Please give approximate dates and briefly describe the nature of any traumatic experiences or injuries you have experienced (example; divorce or termination of significant relationship, auto, or other accidents, broken bones, changes of residence, long term illness, death of a loved one, bankruptcy etc)

Have you ever had any form of counseling therapy? If so please describe what type and when

Do you feel you have one or more healthy relationships in your life?

Do you have a chronic pain condition? If not described already please specify here:

What types of illnesses are you prone towards and how often do you experience them (monthly, yearly etc)

What are your goals and expectations in seeking Chinese Medical treatment?

Please provide any additional information that you feel is significant and was not covered in any of the above questions:

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Arbitration Agreement

Please download and sign the arbitration agreement and bring to your first appointment.

Print & Sign