Pre-Appointment Wellness Form
Please complete the form and submit at least 48 hours before your appointment date.
Email address *
Phone Number *
Your answer
Date of Birth *
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What do you hope to accomplish from your Wellness Hour? *
Your answer
What is the main symptom you are experiencing? *
Your answer
On a scale from 1(mild) - 10 (severe), please write the number that describes you main symptom most of the time. *
Your answer
What percentage of the time do you experience this symptom at that intensity? *
Your answer
Is there anything that makes the symptom worse? *
Your answer
Is there anything that makes the symptom better? *
Your answer
Please describe the quality of pain and/or discomfort that you are feeling? *
Your answer
Does the pain radiate to another part of your body? If so, where? *
Your answer
What steps have you taken to address the issue previously (if applicable)?
Your answer
After addressing your main concern are there any secondary problems you would like to work on?
Your answer
Are you willing to receive acupuncture as a treatment option? *
Do you have any previous injuries? *
If YES, please explain.
Your answer
Are you currently on and medications or supplements? *
If so, what medications and supplements are you taking?
Your answer
How did you hear about Wellness Services at StudioX? *
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