DBA: River Bend FM LLC-Kelly Neu L.Ac.
61555 Parrell Rd Bend, OR 97702
P: 541-318-1000 * F: 541-318-7050 * E: appointments@bendwellnessdoctor.com

General Intake: Acupuncture

First Name: __________________________ MI:_____ Last Name:_________________________________ 
Mailing Address: _________________________________________ City: _______________ State: _____ Zip: _________
Cell Phone: _____________________ Cell Carrier:___________________ Email:_________________________________
Sex: ___M  ___F ___Trans    Age: ______ Date of Birth: _______________ Height: __________ Weight: _________
Marital Status: __Single   __Married __ Divorced  __ Widowed  __ Separated   
Number of Children: __________
Employer: __________________________ Occupation: _________________________Work Phone: ________________
Emergency Contact Name: ________________________ Phone: ___________________ Relationship: _______________
Do you give permission for Dr. Kremer to update your general medical physician with the progress of your condition? ___________
Name of Primary Care Doctor: ____________________________    Have you had Acupuncture before: ___ Yes  ___ No
Who can we thank for your referral: _________________________

Please list any allergies:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

Current Medications, Vitamins and/or Supplements
Med/Vit/Supp	Dose	Reason	

			

			

			

 
 DBA: River Bend FM LLC-Kelly Neu L.Ac.
61555 Parrell Rd Bend, OR 97702
P: 541-318-1000 * F: 541-318-7050 * E: appointments@bendwellnessdoctor.com

Past Illnesses, Injuries, Surgeries:
Year	Test	Findings	

			

			

Special Imaging and/or Tests (MRI, CT, X-Ray, etc):
Year	Treatment	Outcome	

			

			

Please provide a sample of your daily diet:
Time	Food/ Beverage/ Amount	Comments