Intake Form

Emergency Contact Information

Doctor Information

Insurance Information

Acupuncture
Eating Habits
Emotion / Mood
Energy
Energy Level
Female Health
HT/SI (Fire)
KID/UB (Water)
LIV/GB (Wood)
LU/LI (Metal)
Oncology
Prenatal
SP/ST (Earth)
Brain Disorders
TMJ (Jaw)
Area of Complaint
Headaches
Blood
Cardiovascular
Endocrine
Family History
Gastrointestinal
Hearing
Immune
Kidney
Musculoskeletal
Neurological
Reproductive
Respiratory
Skin
Miscellaneous

Additional Information




Need Help?
516-697-7109