ACUPUNCTURE - Medical History

Please fill out this form as best you can so we can provide you with the most relevant and appropriate service.

First Name

Last Name

Allergies

What are your health concerns and goals of treatment?

Medication and Reason for taking

Vitamins & Supplements and Reason for taking

Hospitalizations (Year - Illness/Operation)

Do you have a pacemaker?

Number of Live births

Number of Miscarriages

Number of Abortions

Other Information