Acupuncture and TCM History Intake Form

We incorporate state-of-the-art equipment in our analysis of your healthcare needs. We individualize your care program to fit your specific lifestyle.

If having high energy, reducing the negative effects of stress and enjoying life to its fullest are important to you, then please contact our office today so we can help you!

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Family History
Your Past Medical History/Illnesses:

Habits/Excessive Usage: (Please tell us how often & how much)

Chief Complaint/Reason For Your Visit: