Have you had Acupuncture before?
How did you hear about us?
What Is The Reason For Your Visit (Please list main complaint.)*
Is there anything that improves or aggravates your main issue?
Additional health concern & approximate date of onset
Additional health concern & approximate date of onset
Additional health concern & approximate date of onset
Are you under a physician’s care for any of your health concerns? (please describe)
Date of last physical exam
Please list any hospitalizations and/or surgeries
Please check all that apply
Please list prescription or over the counter drugs you are currently taking, dosage, what purpose, and date you began taking
Please list vitamins, minerals, and supplements you are currently taking, dosage, what purpose, and date you began taking