New Patients

Health history questionnaire

Please fill out the following information as completely as possible. If a section or question does not pertain to your health concern please leave it blank.

1- Personal Information

Have you been treated by acupuncture before? YN

I have been evaluated by a physician for the condition(s) being treated within the past 12 months:YN

May we share information with your other healthcare providers? YN

2- General Health History

Describe your main health concerns along with any diagnoses you have been given:

Rate the following symptoms that you have experienced on a scale from 1-10: (10 being worst).

Visual problems / floaters

Blurred vision / poor night vision

Red / dry / itchy eyes

Headaches / migraines


Muscle twitching / spasm

Neck / shoulder tension

Brittle nai