Acupuncture Registration | AcuHealthcare

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Acupuncture Patient Registration

To register, please take the time to fill out the information below.

First Name

Last Name

Email

Date of Birth

Phone

Address

Occupation

How did you hear about AcuHealthcare?

Marital Status

No. of Children

Ages of Children

Reason for visit today?

Doctors Name

Doctors No.

If yes, for what?

Any other Current Therapies?

Accidents/Injuries/Falls/Traumas

Major Illnesses/ Surgery (dates)

Current Medications (Including Vitamins)

Sleep Pattern

Energy LevelLowOkayAverageGoodAwesomeEnergy Level

Stress LevelNot StressedNot often StressedStressed 3-5 times a weekStressed once a dayVery often StressedStress Level

Musular Skeletal

Neck/Shoulder Pain

Joint Pain

Back Pain

Muscle Pain

Arthritis

Circulatory

H/L Blood Pressure

Varicose Veins

Blood Clots

Heart Palpitations

Tired Legs

Respiratory

Frequent Colds

Hay Fever

Sinusitis

Asthma/Wheezing

Cough

Genitourinary

Frequent Urgent Urination

Wake to Urinate

H/L Libido

Pain on Urination

Kidney Stone

Skin & Hair

Eczema/Psoriasis

Dry Skin/Hair

Itching

Acne

Hair Loss

Gastrointestinal

Constipation/Diarrhea

Bloating

Nausea

Hemmorrhoids

IBS

Neuropsychological

Headaches/Migraines

Poor memory

Irritability

Depression

Anxiety

Senses

Glasses or Lenses

Ear Infections

Deafness

Vertigo/ Dizziness

Tinnitus

Reproductive

Pregnant

Breast-feeding

Heavy/ Clots

Painful

Scanty

PMT

F-Last Period

I agree to give 24 hours notice if I cannot attend my appointment (to be given to someone in need of urgent treatment). If I do not give notice I agree to pay a fee of €30. If I do not attend my appointment and I have not called, I agree to pay the full consulting fee.

Your Signature

© 2020 by Zephan MacBennet

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