Health History & Intake Form

The following form is designed to capture an in-depth overview about your current health picture. Please answer honestly and with as much relevant information as you can. I will then review your initial intake and create an accurate diagnosis and effective treatment plan, tailored to your specific health goals.

Please don't hesitate to email me should you have any questions: kim@urbanacupuncture.co.uk.

Question Title

* 1. Personal Details

Question Title

* 2. Do any of the following apply to you?

Question Title

* 3. Medical History // Please make a note of any major or recurrent illnesses, conditions, accidents or operations you have had at any point during your life. Also include your age, or the year each event occurred.

Question Title

* 4. Medication & Supplements // Please list all medication/supplements you are currently taking, the reason why you're taking it and how long you have been taking it for. If you feel it is relevant to make a note of previous medications then please do.

Question Title

* 5. Presenting Conditions // Please provide information about why you are coming for treatment, including the following details: Onset, development, better for, worse for, intensity scale etc.

Question Title

* 6. Patient Priorities // Please make a note of what would you like to achieve from your acupuncture treatments

Question Title

* 7. Cycle & Hormonal Health // Is your cycle regular? How many days is it? Is your flow heavy/light? How long does your bleed last? What colour is the blood? Do you have any clots? Do you notice pre-menstrual spotting/spotting around ovulation? Do you experience pain? Do you get PMT symptoms? If so, please provide details. Have you ever been diagnosed with cysts, fibroids or any other gynaecological related issue?

Question Title

* 8. Current Health // Please indicate the frequency and severity of the following symptoms - grading where possible:

0 = never 1 = rarely 2 = occasionally 3 = often/always

If you feel it’s necessary to expand on any of the above then there is space below, or I may ask you specific questions on the day of your treatment.

Question Title

* 9. Yoga // Do you have any physical limitations, injuries or preferences that could affect the yoga poses we work with on the day?

Question Title

* 10. Consent of Treatment // To ensure that there is no misunderstanding between acupuncturist and
patient, an acupuncturist should give a full explanation to the patient of alll procedures to be undertaken.

We will be sending you a video next week with full details about your treatment. Furthermore, I will talk you through exactly what we will be doing on the day. Your comfort & understanding is my absolute priority so please don't hesitate to call me directly should you have any questions or concerns about treatment.

Please check the box below to confirm you have read and understood the above.

T