Calvert Rejuvenations Acupuncture Survey

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Record my email address with my response

I prefer the following days and times:

Morning (9a-12p)

Afternoon (12:30p-4p)

Evening (4:30p-7:00p)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Have you experienced acupuncture before?

Yes

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Does your current insurance plan include acupuncture benefits?

Yes

I'm not sure

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Which is your primary insurance carrier?

Bluecross Blueshield

Aetna

Kaiser

Cigna

United

Humana

Medicare

Other:

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Please describe your reasoning for seeking acupuncture care:

Sciatica

Fatigue

Mental Illness (PTSD, Depression, Anxiety, Rumination)

Headaches

Women's Health (Menstrual pain, Infertility, Menopause, Lactation, Postpartum)

Pregnancy (Breech, induction, etc.)

Night Sweats

Gastrointestinal Discomfort (Constipation, Diarrhea, Cramping, Ulcers, Acid Reflux)

Weight loss

Respiratory distress

Muscle pain

Neuromuscular Condition (Bell's Palsy, Multiple Sclerosis, Myasthenia Gravis, etc)

Sleep Disturbances

Skeletal pain

Arthritis

Allergies

Confusion, Disorientation

Other:

Send me a copy of my responses.

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