New Patient Form | Matt Han Acupuncture

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First name*

Last name*

Gender*

Male

Female

Other

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone*

By providing your phone number, you agree to receive SMS appointment reminders and updates from Matt Han Acupuncture. You can opt out anytime by replying STOP.

Email*

Birthday*

Month

Day

Year

Age

Marital Status

Single

Married

Divorced

Widowed

Separated

Prefer Not to Answer

Occupation:

Emergency Contact/Relationship

Phone

Please describe the main reason for your visit:

Please indicate if you have any of the following:

Cardiac pacemaker

Seizure disorder

Bleeding disorder/Blood thinners

Fainting disorders

High blood pressure

Believe you are or may be pregnant

Hepatitis

Tuberculosis

Other

List any major illnesses, surgeries, accidents, or injuries (childhood and adult):

List all medications or supplements, including herbs and vitamins you are currently taking:

Lifestyle Habits:

Cigarettes

Caffeine (coffee, tea, cola)

Alcohol

Recreational drugs

Describe painful areas. Rate on pain scale 1(none) to 10(worst).*

Please check all symptoms 1

Cold hands/feet

Fatigue

Feverish in the afternoon or flushes

Heat sensation in hands, feet, chest

Night sweats

Catch colds easily

Sweats easily during daytime

Dizziness

Please check all symptoms 2

Palpitations

Anxiety

Chest pain

Insomnia

Depression

Please check all symptoms 3

Cough

Sinus congestion

Dry mouth, throat, nose, or skin

Allergies seasonal or food

Stiff neck/shoulders

Please check all symptoms 4

Low appetite

Loose stools

Constipation

Bruises easily

Mental heaviness or fogginess

Swollen hands/feet

Burning sensation after eating

Bad breath

Mouth, canker or cold sores

Bleeding, swollen or painful gums

Heartburn/belching

Stomach pain

Vomiting/nausea

Please check all symptoms 5

Tight/suffocating feeling in chest

Bitter taste in mouth

Dry eyes

Skin rashes

Headache

Numbness of hands and feet

Muscle spasms, twitching, cramping

Seizures/convulsions

Sore, cold or weak knees

Low back pain

Frequent urination

Memory problems

Hair loss

Ringing in ears

Urine is:

Normal color

Clear

Dark yellow

Reddish

Cloudy

Scanty

Bad odor

Burning

Painful

Difficult

Urgent

Libido (sex drive) is

Normal

Low

High

WOMEN ONLY: 1. Are you pregnant now?

Yes

No

WOMEN ONLY: 2. Is your menses cycle regular?

Yes

No

WOMEN ONLY: 3. Average number of days in flow:

WOMEN ONLY: 4. The flow is

Normal

Heavy

Light

WOMEN ONLY: 5. The color is:

red

dark

purple

light brown

brown

WOMEN ONLY: 6. Do you have the following menstruation related symptoms?

Blood clots

Cramps

Nausea

Breast distention

PMS

Bleeding between periods

Heavy vaginal discharge between periods

WOMEN ONLY: 7. Birth control

MEN ONLY:

Discharge

Pain or swelling of testicles

Ejaculatory problems

Impotence/erectile dysfunction

"Save Time at Your Appointment!"

Filling out this form in advance will save you time during your visit, as you won't need to complete it in the office. The process takes about 10 to 15 minutes and ensures a smoother experience for your first appointment.

By providing your phone number, you consent to receive automated text messages from Matt Han Acupuncture regarding appointments, promotions, and important updates. Message and data rates may apply. Reply STOP to unsubscribe.

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