In preparation for your first acupuncture visit, we'll need to get some preliminary information from you.

Contact Information
Name *
Address *
Best Way to Reach You By Phone *
Best Way to Reach You By Phone
Emergency Contact Name
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Phone
Physician's Name
Physician's Name
Physician's Phone Number
Physician's Phone Number
Personal Information
Birthday *
Health History
In my life, I have:
Prescription blood thinners such as warfarin/coumadin
Have you ever been diagnosed with any of the following sexually transmitted diseases?
More about sleep: *
Lifestyle is hugely important in the realm of eastern medicine. Work doesn't necessarily mean an exchange for money, either: avid volunteers, stay at home parents, and students are all working hard.
You've made it to the end of the form!