New Patient Intake Fill Out Intake Form Please complete the following form before your first appointment. Greenlake Acupuncture1111 N. 82nd Street, Seattle, WA 98103PERSONAL INFORMATIONPrefixMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Middle NameLast Name *SexMFBirthdate *BirthplaceOccupationEmployerAddress – StreetAddress – CityAddress – StateAddress – ZIPHome PhoneWork PhoneCell PhoneEmailSocial Security NumberHealth Insurance CompanyReferred ByMarital StatusSingleMarriedDivorcedWidowedOtherEmergency Contact – NameEmergency Contact – RelationshipHTMLHEALTH HISTORY INFORMATIONFamily Doctor – NameFamily Doctor – PhoneFamily Doctor – Date of Last VisitSpecialist for Current Condition – NameSpecialist – PhoneSpecialist – Date of Last VisitReason for Today’s Visit *Please include when it started and what makes it better or worse.Since WhenWestern Doctor’s Diagnosis for Current Problem *List of all medications you are taking *HTMLList all major operations you have had *List any other treatment therapies you are undergoing currently *List any allergies *Have you had acupuncture before?YesNoAre you nervous about needles?YesNoDo you have a tendency to faint?YesNoDo you bleed for a long time or bruise easily?YesNoHave you ever had hepatitis?YesNoDo you have diabetes?YesNoDo you have high blood pressure or heart problem?YesNoWomen – Are you pregnant?YesNoWomen – Are you currently menstruating?YesNoHTMLAcupuncture Consent Form I hereby agree to accept the acupuncture treatment and I have been made aware of the possibility of complications that may result from this procedure. By checking the box below and typing my full legal name, I agree that this constitutes my electronic signature under the U.S. ESIGN Act and UETA and has the same force and effect as a handwritten signature. Submission date/time and IP address may be recorded for verification purposes.I consent to treatment as stated above *Yes, I consent to treatment as stated above.Signature (type your full legal name) *Type your full legal name exactly as it appears above.Re-enter full name to confirm *Date *Initials *Submit
