Patient Questionnaires | Wellspring Classical Acupuncture

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Date of Visit*

What is your main complaint?*

What is your favorite season?*

What is your favorite color?*

What is your favorite taste?*

What is your favorite music?*

What themes or images frequently appear in your dreams?*

Describe something you felt you had to do, no matter what, that caused people to say you "must be crazy."*

What would you love to do if you had the chance?*

What things bother you the most that you cannot forgive?*

Health Questionnaire

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Patient Questionnaire