Before Your First Appointment

Please complete the following form and submit before your first acupuncture appointment.

Also, please check the Covid Safety measures still being taken to reduce Covid transmission, and remember to check the box at the end of the form.

Name *

First

Last

Email *

Phone Number/s *

Mobile preferred

Date of Birth

Address *

Post Code *

GP name/surgery *

Main symptoms *

Please describe the main reason that you are seeking acupuncture treatment – symptoms, timeline, causes (if known)

Any Other Medical Conditions? *

Medications *

Name of medication, dose. Say “none” if applicable.

Sleep

Any difficulties such as difficult to drop off, wakeful, difficulty getting back to sleep, restless, hot, vivid dreams?

Headaches

Are you prone to headaches or migraines? If so, please describe frequency, triggers, location, type of pain etc.

Digestion

Any issues such as intolerances, bloating, reflux, irregular/loose/difficult bowel movements

Nutrition

Please list your TYPICAL breakfasts, lunches, evening meals, snacks, drinks. Are you vegetarian/vegan?

Eyes & Ears

Any hearing loss, tinnitus, prone to infection, dry eyes, floaters

Musculoskeletal

Any pain, joint issues, arthritis etc

Do you tend to feel the cold or often feel warm?

Do you have particularly cold hands/feet, sweat a lot, feel warm at night – need to stick your feet out of the bed!

Respiratory system – asthma, hayfever, sinus issues, mucusy

Emotions

Are you pretty easy going or a worrier? Can you fly off the handle?

Do you smoke/drink?

Please give estimated amounts

Anything else that you may think relevant

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