Patient Intake Form

Collaborative Care Intake Form

Please complete this document as thoroughly as possible. Some of the questions that follow may seem unrelated to your condition, but may play a major role in assessment and treatment. All information is strictly confidential. Please allow 15 - 20 minutes to complete the form. To exit this form at any time, just click on the "Collaborative Care" title at the top of the page. Incomplete forms will not be submitted or saved.

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Patient Contact Information
Name*
FirstLast
Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Employer
Occupation
Home Phone
Work Phone
Email
General Patient Information
Date of Birth
Place of Birth
Guardian
FirstLast
If under 18 years of age, please specify a legal guardian.
Height
Weight
Gender
- Male
- Female
Please list any allergies to drugs and/or medications:
Physician
Physician Phone
If you were referred to Collaborative Care, who referred you?
Emergency Contact Information
Emergency Contact #1*
FirstLast
Emergency Contact #1 Phone*
Relationship to Patient
Emergency Contact #2
FirstLast
Emergency Contact #2 Phone
Relationship to Patient

Patient Informed Consent
1. I hereby voluntarily consent to be treated by acupuncture and or Chinese Herbs administered by Jacqueline O’Neill, hereinafter referred to as "Practitioner”.

2. I understand that acupuncture is performed by the insertion of fine, pre-sterilized disposable acupuncture needles (with or without the addition of electric current) through the skin, or the application of heat to the skin, or both, at certain points on the body, in an attempt to improve body function and/or relieve pain.

3. I acknowledge that, although rare, certain side effects may result from acupuncture. These can include bruising, mild pain or discomfort, a feeling of weakness, fainting, nausea, and a temporary aggravation of symptoms. These effects are unusual and of short duration.

4. I accept the fact that no guarantee is made concerning the use and effects of acupuncture or Chinese herbs.

5. I understand that I may stop treatment at any time.

6. I further understand that the evaluation given me is an energetic assessment of the acupuncture meridian network, and in no way purports to be, or replaces a western medical examination or diagnosis. In the course of the evaluation, there may be references to the state of various "organs", such as the heart, liver, spleen, kidneys, etc., which actually refers to the energetic channels of the same name.

7. I acknowledge the fact that Jacqueline O’Neill is not and does not profess to be a western-trained medical doctor and does not advise on the use of medically prescribed pharmaceuticals or medical treatment, nor does the Practitioner give any substances by injection.

8. I acknowledge that Jacqueline O’Neill has completed a minimum of three years training In Acupuncture and Oriental Medicine, is National Board Certified (NCCAOM) and a Licensed Acupuncturist (L.Ac.) in the state of Illinois. 9. The clinical data gathered in practice, without names, may be used for statistical research and teaching purposes.
You must check this box to complete your intake form.*
- I understand and agree to the patient terms of consent.
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Collaborative Care Intake Form

Step 1 of 5

Patient Contact Information

General Patient Information

Emergency Contact Information

Patient Concerns

Medical History

Please check any systemic conditions or symptoms that you presently have or have had in the past.

Please check any other conditions or symptoms that you currently have or have had in the past.

Habits and Nutrition

For Male Patients

For Female Patients

Patient Informed Consent

Our Services

Our Practice

Resources

Office Hours

Download Patient Intake Forms