Acupuncture Intake Form

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Thank you for your response. ✨

You cannot save you work, so fill out this form when you have time to do it all in one sitting.

Please fill this out 24 hours or more prior to your appointment. DO NOT fill this out if you don’t have an appointment with our Acupuncturist Susan Mayo, L.Ac. The following 17 tab questionnaire asks important questions which will help Susan help you. It may take 20 minutes to fill out, please take your time and be thorough.

Digestive Symptoms: (check all that apply)
Bowel Pattern:
Urine Pattern:
Thirst Pattern:

Energy is Usually Lowest:

Please mark Yes or No for each symptom.

Headaches/Migraines(required)
Dizziness/Vertigo(required)
Brain Fog(required)
TMJ/Clenching/Jaw Tension and Pain(required)
Sinus Congestion(required)
Sore Throat/Hoarseness(required)
Skin Issues(required)
Hair Changes(required)
Facial Pain(required)
Seasonal Allergies(required)
Mouth /Tongue Sores(required)
Bleeding Gums/Toothache(required)
Cold Sores(required)
Dry or Itchy Throat(required)
Feeling a Lump in the Throat(required)
Body Aches(required)
Joint Pain(required)
Weight Changes(required)
Chest/Breathing Symptoms
Limb Symptoms:
Sleep Issues:
Sweating:

Ear Symptoms:
Eye Symptoms:

Temperature Tendencies:
Emotional Patterns:
Do you feel like your emotions are in dysregulation or fluctuating lately?
Do you have high stress in your life right now?
Do you feel as though you are managing/coping with stress well?
Sexual health concerns: (for men & women)

FEMALE ONLY (Male skip to the bottom and click NEXT)

Cycle Pattern:

CHILDREN ONLY (Newborn to 17) All others click SUBMIT

For child patients, current concerns may include:

Thank you for taking the time to fill out this important form.