ACUPUNCTURE INTAKE FORM

1. Name: *
1. Name:
Medical History
7. Lung & Large Intestine Meridian/Organ Network
If you are currently experiencing these symptoms, or have in the last 3 months, please check the appropriate box
8. Kidney & Bladder Meridian/Organ Network
If you are currently experiencing these symptoms, or have in the last 3 months, please check the appropriate box
9. Liver & Gallbladder Meridian/Organ Network
If you are currently experiencing these symptoms, or have in the last 3 months, please check the appropriate box
10. Heart & Small Intestine Meridian/Organ Network
If you are currently experiencing these symptoms, or have in the last 3 months, please check the appropriate box
11. Spleen & Stomach Meridian/Organ Network
If you are currently experiencing these symptoms, or have in the last 3 months, please check the appropriate box
12. Skin
If you are currently experiencing these symptoms, or have in the last 3 months, please check the appropriate box
13. Other
If you are currently experiencing these symptoms, or have in the last 3 months, please check the appropriate box
Date of heart attack
Date of stroke
14. Menstrual Cycle
If you are currently experiencing these symptoms, or have in the last 3 months, please check the appropriate box
What colour(s)?
Period usually lasts how many days?