Renessence Acupuncture

Renessence Acupuncture - Intake Form

Please complete the following information prior to undergoing your Acupuncture session
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of birth/upbringing*

GENERAL INFORMATION
Are you currently under the care of a medical professional? If YES, please provide information you deem necessary for the acupuncturist to know. If NO, when was the last time you had contact with medical health professionals, and do you deem it necessary to share?
What are your most important health concerns? List them in order of importance:
Do you smoke? If yes, how many cigarettes pr. day/week?
Do you drink alcohol? If yes, how many drinks pr. day/week?
Do you have any chronic illnesses or family history of illnesses?

Renessence Acupuncture - Intake Form