top of page

Medical Questionnaire

Help us understand your physical condition.


Please take the time to fill out this questionnaire carefully. The information provide will assist me in formulating a complete health profile for you. All your answers are absolutely confidential under The Health Insurance Portability and Accountability Act of 1996 (HIPAA). If you have any questions, please ask. 

Personal Medical History

Please check any conditions or symptoms you are currently experiencing.

Family Medical History

Please check any condition that applies to your immediate family. 


Please check the box if you have had any of these items listed below in the last year.


Skin & Hair

Head, Eyes, Ears, Nose and Throat








Acupuncture Consent to Treatment

I hereby request and consent to the performance of acupuncture treatments and other traditional Chinese medical procedures on me (or on the patient named below, for which I am legally responsible) by the below name licensed acupuncturist.


I understand that methods or treatments may include but are not limited to acupuncture, moxibustion, cupping, bloodletting, electrical stimulation, Tui Na (Chinese massage), Gua Sha, Chinese or Western herbal medicine, and nutritional counseling.


The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine. I understand the same herbs may be inappropriate during pregnancy and will inform my practitioner immediately of pregnancy status.  If I experience any gastro-intestinal reactions to the herbs I will inform the acupuncturist immediately.  


I have been informed that I have a right to refuse any form of treatment.  I have read, or have had read to me the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures.  I also understand there is always a possibility of an unexpected complication and I understand that no guarantee can be made concerning the results of treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

I understand it may be necessary for my practitioner to contact another one of my health care providers in order to coordinate medical treatment, to discuss an emergency situation and/or to share appropriate medical information. My below initials gives my practitioner permission to release my medical records for the reasons listed above

I agree to pay the full charge for any missed or forgotten appointments without 24-hour notice of cancellation.

I agree to pay all charges incurred for services rendered, over and above insurance coverage

Thanks for submitting!

bottom of page