Dr Su Lin Wan's Meditative Acupuncture Questionnaire

Today's

DayMonthYear

Name*

First NameLast Name

Date of Birth*

DayMonthYear

Gender

FemaleMale

Address*

Street Address

Street Address Line 2

CityState

Postal CodeCountry

Phone Number*

E-mail*

Medicare Number*

Medicare IRN*

Medicare Expiry Date*

DayMonthYear

How did you hear about this?

Have you had acupuncture before?*

YESNO

Have you meditated before?*

YESNO

Please TICK if you have any of the following:*

Please write any current health conditions:

Do you have any sensitivity to medications?

YESNO

If yes, please describe:

Do you have Abdominal pain?

YESNO

Do you have a tendency for diarrhea?

YESNO

Do you have a tendency for constipation?

YESNO

Do you fall sleep easily?

YESNO

Do you wake often?

YESNO

How many hours do you generally get at night?

Are you happy with your level of energy?

YESNO

On a scale of 1-10, (10 very high) what is your energy?

My energy is highest at what time of the day?

:HourMinutesAM/PM Option

My energy is lowest at what time of the day?

:HourMinutesAM/PM Option

Do you have difficulty with concentrating?

YESNO

Thank you for completing the form.

PLEASE wear loose pants or a skirt if possible on the day.

I look forward to seeing you at the session.

~Su Lin

PRIVACY STATEMENT

Your privacy is important to Dr Su Lin Wan. This privacy statement provides information about the personal information that Dr Wan collects, and the ways in which Dr Wan uses that personal information.

Personal information collection: Personal details will be collected to enter into our medical database.

Using Medical information: Dr Su Lin Wan may use your medical information to help with management of your acupuncture session. This is confidential and will only be viewed by Dr Su Lin Wan.

Securing your data: Dr Wan will take reasonable technical and organisational precautions to prevent the loss, misuse or alteration of your personal information. Dr Wan will store all the personal information you provide on its secure servers.

Our Marketing practices: Dr Wan may utilise personal information to distribute -including via mail, SMS, email, telephone, online or in person; information about Dr Wan’s products, services, publications and news that you might be interested in with your permission.

Contact : If you have any questions about this privacy policy or Dr Su Lin Wan’s treatment of your personal information, please write by email to drsulinwan@gmail.com

Do you consent to have information sent to you about Dr Su Lin Wan's services?

YESNO

Dr Su Lin Wan's Meditative Acupuncture Questionnaire

Personal Details

Medical History

Gut Health

Sleep

Energy

Concentration