AtwoodAcupunctureCenter,LLC.docVIP

Atwood Acupuncture Center, LLC 111 S. First St., Suite 170 ? Madison, WI 53704 ? 608-256-5080 CONFIDENTIAL CLIENT INFORMATION FORM: ACUPUNCTURE MASSAGE THERAPY Name:_____________________________ Date of Birth: ________________ Today’s Date:____________ Address:__________________________________________________________________________________ City:________________________ State:________ Zip:_________ Phone: _________________________ In case of an emergency who should be notified? _________________ Phone: _________________________ How did you hear about us? Internet Outdoor Sign Yellow pages Ad Event______________________ Referred by ________________________ Gift Certificate________________ Other_________________ 1. What is the purpose for your visit today? ____________________________________________________ (or) Check One: ___Soft Tissue Pain ___Loss of Function ___Sports Injury ___Stress Relief/Relaxation ___Other: please specify______________________ 2. Have you had or do you have any of the following? Past Present Past Present ____ ____ Headaches ____ ____ High Blood Pressure ____ ____ Neck Pain ____ ____ Chest Pain ____ ____ Upper Back Pain ____ ____ Stroke ____ ____ Mid Back Pain ____ ____ Angina ____ ____ Low Back Pain ____ ____ Blood Clotting Disorder ____ ____ Shoulder Pain ____ ____ Varicose Veins ____ ____ Elbow/Upper Arm Pain ____ ____ Diabetes ____ ____ Wrist Pain ____ ____ Kidney Stones ____ ____ Hand Pain ____ ____ Bladder Infection ____ ____ Hip/Upper Leg Pain ____ ____ Painful Urination ____ ____ Knee/ Lower Leg Pain ____ ____ Abdominal Pain ____ ____ Ankle/ Foot Pain ____ ____ Ulcer ____ ____ Jaw Pain ____ ____ Hepatitis ____ ____ Joint Stiffness ____ ____