Private and Confidential

Name *
Have you had acupuncture before? *
Are you allergic to any foods, medicines or materials? *
Have you had botox/fillers/cosmetic surgery in the last 6 months? *
Are you taking an prescription drugs, natural/homeopathic remedies? *
Are you attending/receiving treatment from a doctor, clinic, hospital or specialist? *
Do you bruise easily? *
Are you pregnant/planning on becoming pregnant? *
Medical History
Please check all that apply.
Do you have...?
Do you find it difficult to relax? *
Do you see natural daylight in your workplace? *
Do you smoke? *
Do you drink alcohol? *
How are you energy levels generally? *
(1 being not stressed, 10 being very stressed)
(1 being not stressed, 10 being very stressed)
By checking this box I confirm that all the information I have given is current and correct. *
Date *