Insight Wellness

Your Insight to Health & Wellness

Acupuncture Intake

Please fill out the following information in as much or as little detail as you prefer.  If there are portions you do not wish to answer, or if they do not apply, please answer "No."  Please be aware that you must sign the informed consent form in order to seek treatment.  No information is shared or utilized in any way, other than for your treatment.  As we do not accept insurance, your answers are not submitted to or shared with any insurance company.

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 Single   Partnered   Married   Separated   Divorced   Widowed 







List your drugs and over the counter drugs, including vitamins & inhalers

Please list all known Allergies to Medications

Exercise
 Sedentary (No Exercise)
 Mild Exercise (ie., climb stairs, walk 3 blocks, golf)
 Occassional Vigorous Exercise (work or recreation, less than 4x/week for 30 min)
 Regular Vigorous Exercise (work or recreation 4x/week for 30 min. or more)


Diet
 Yes   No 

 Yes   No 


Caffeine


Alcohol
 Yes   No 

 Yes   No 


Tobacco
 yes   no 


Drugs
 Yes
 No

 Yes
 No


Sex
 Yes   No 

 Yes
 No

 Yes   No 


Family Health History

 Male   Female 

 Male   Female 

 Male   Female 

 Male   Female 

 Male   Female 

 Male   Female 


Mental Health
 Yes
 No

 Yes   No 

 Yes   No 

 Yes   No 

 Yes   No 

 Yes   No 

 Yes   No 

 Yes   No 


Women Only

Click "No" to everything if you are NOT a Woman, or if nothing applies to you.

 Yes
 No

 Yes
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 Yes
 No

 Yes   No 

 Yes
 No

 Yes
 No

 Yes
 No

 Yes
 No


Men Only

Check "No" to Everything if you are NOT a man, or if nothing applies to you.

 Yes
 No

 Yes
 No

 Yes   No 

 Yes
 No

 Yes
 No

 Yes
 No

 Yes
 No

 Yes
 No

 Yes   No 


Other Problems

 

Check if you have, or have had, any symptoms in the following areas.  Follow each with a brief explanation

 yes   no 

 Yes   No 

 Yes   No 

 Yes   No 

 Yes   No 

 Yes   No 

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 Yes 

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 Yes   No 


Cancellation Policy

 

If for any reason, you cannot make your appointment time, please give 24 hours notice.

Late arrival may result in a shorter session.  Arrival 15 minutes past the appointment start time will be considered a No-Show.  It is the client's responsibility to pay for the full scheduled time.  You may not substitute, change or alter appointment type or start time with less than 24 hours notice.  Payment is due when services are rendered.  If you are unable to give 24 hours notice, or arrive 15 minutes past start time of your appointment, a cancellation fee will be assessed.  Fees are $25 for sessions under 1 hour.  Fees are $40 for sessions over 1 hour.  Fees are due within 48 hours of the cancellation/no-show/late arrival.  This fee is necessary to reschedule, as well as to keep any pre-paid sessions on our schedule.  By typing your name, you are providing an electronic signature, verifying your understanding and agreement.  Thank you.

Please type in your name.  This acts as a digital signature

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