Eastern Approaches – New Client Questionnaire

These questions are a guideline for the practitioner to interview you with; your answers are completely confidential. If you have anything that is not listed, please feel free to write in the 'notes' section.

Please complete as much as possible, print and bring in with you to your appointment.

Name

Address
(Street Address, City, State, and Zip Code)

Phone (home)

Phone (work)

Occupation

Age

Birthdate

Marital Status

married

single

widowed

divorced

In case of emergency, notify

You were referred by

Have you been treated by Acupuncture or Oriental Medicine before?

yes

Tell us about your problem
Main Complaint
How long ago did this occur and how?
Do you have a diagnosis for this problem?
How are you presently treating this?
What aggravates this condition?
Any health conditions related to it?
If this is a pain condition, on a pain scale from 0 to 10, where is the level of pain?
Any medications or vitamins?
Any prior surgeries?
Is there any disease or condition that is "family" in nature?

Do you suffer from any of the following?
	headaches	circulatory	bladder problems	lung problems
	neck pain	abdominal pain	blood pressure problems	diabetes
	arm/shoulder pain	sinus trouble	hot flashes	constipation
	back pain	heart trouble	prostate problems	loose stool
	hip/leg pain	palpitations	digestive disorders	swollen joints
	chest pain	kidney problems	depression	poor memory
	insomnia	nervousness	anger	anxiety
	dizziness	fatigue	anemia	numbness

General
Additional Notes

By submitting this form, I understand that all services rendered me
are charged directly to me and that I am personally
responsible for payment at the time services are rendered.

Please print out and bring this form
with you to your appointment

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please use your browser's print button

82 Palomino Lane, Suite 501
Bedford, NH 03110
603-548-0893