Intake Form

New Patients: Please fill out the following consultation form, and send it to us, prior to your first appointment so that we can better service your needs.

If you have a question fill out the short form here, or give us a call at (312) 399-4919, or use direct e-mail: larisaturin@chicagoacupuncture.com

Step 1/4


Date:

Mobile Phone:

First Name:

Last Name:

Work Phone:

Home Phone:

Age:

Gender:

Male

Female

Occupation:

Home Address:

City:

State:

Zip:

Your E-Mail:

Referral:

Complaints:

How many times per year do you get a cold or the flu?

Diet:

Family medical history:

Step 2/4


Emotions:

normal

problem

Describe:

Energy:

normal

problem

Describe:

Sleep pattern:

normal

insomnia

Falling asleep:

Waking up:

wake up at night and cannot go back to sleep again

Sleep quality:

Describe:

Menstrual cycle:

regular

irregular

Age of outset:

Date of last period:

How many days per cycle?

How many days did it last?

Color:

regular

irregular

bright red

purplish

When did you feel pain?

Yes

No

Menstrual pain:

Yes

No

When did you feel pain?

Where did you feel pain?

Emotions around period:

normal

abnormal

When do you feel most emotional?

What emotions do you feel?

Describe:

Step 3/4


Temperature:

normal

abnormal

Describe:

Sweating:

normal

abnormal

Describe:

Sensitivity & Allergy:

normal

problem

Describe:

Bowel movement:

normal

abnormal

Describe:

Step 4/4


Body weight:

normal

overweight

underweight

How many pounds would you like to loose?

How many years ago did you first start to gain weight?

Are you following a weight control program at this time?

yes

no

Describe:

Drinking:

normal

abnormal

Describe:

Urination:

normal

abnormal

Describe:

Please note that if you make an Appointment, you are required to give at least a 24 hour notice if you cannot make it, otherwise you will be charged the full price of the appointment.

Check here if you accept these terms.

Please, make sure to fill out all required fields marked with * After you press submit, if you missed a required field, the form will not submit, but it will mark in red the missing fields to remind you to fill them in. Please do so, and press send again.