Acupuncture Chart For Christine Richards, M.D. (MA), Dr. Ac., DAc AC #1120

Client's Name	Date of Treatment
Address	City	Postal Code
Fax:	E-Mail:
Home Phone	Work Phone
Date of Birth	Occupation
Referred by	Family Doctor
Reason for Treatment:
Have you had acupuncture done before? When? Where?
Under medical treatment now? If yes; please give me some details:
List of Current Medications & Supplements:	List Environmental & Drug Allergies:
Last Visit to Doctor?
Hospitalizations & Surgeries:

Headaches		Eating Pattern ie 3 meals a day? Vegetarian etc.
Sleep Pattern Interrupted Sleep?		Digestive - any problems or symptoms?
Bowel Functioning 1 - 3 a day? Constipation? Diarrhea?		Blood Disorders?
Stress Level	High Med Low	Pregnant?
Reproductive Problems?		Blood Pressure

Disclaimer: The therapist, Christine Richards DAc, does not make any claim of replacing any medical therapy. Information exchanged during any session is confidential. The treatment has been described to me, along with the risks and I accept the outcome without holding the therapist responsible in any way. I certify that the above information is correct to the best of my knowledge. I will not hold the therapist responsible for any errors or omissions that I have made in the completion of this form.

Date: _______________ Client's Signature of Consent for Treatment: _________________________________________________ _____________________________________________________________________

Point Selection: Initial Visit

Date: Point Selection

Date: Point Selection