Acupuncture Intake Form
*Check Any / ALL that apply*
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Cell Phone Number (include area code) *
Your answer
Email Address *
Your answer
Spleen / Stomach *
Required
Heart / Pericardium *
Required
Lung / Large Intestine *
Required
Kidney / Urinary Bladder *
Required
Liver / Gall Bladder *
Required
*
Required
Kidney Yin Deficiency *
Required
Kidney Yang Deficiency *
Required
Spleen (Qi, Blood, and /or Yang Deficiency) *
Required
Blood Deficiency *
Required
Blood Stasis *
Required
Liver Qi Stagnation *
Required
Heart (Any Disorder) *
Required
Excess Heat *
Required
Dampness *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service