Lauren Brinkowski, L.Ac, MAOM

Name

First

Last

Date

Email *

Phone *

Date of Birth *

Age

Height

Weight

Gender

Female

Male

Non-Binary

OtherOther

What pronouns do you use?

e.g. she/her, he/him, they/them, etc

Occupation

Marital status

Referred by

Emergency Contact and Phone Number

Have you been treated by acupuncture or Chinese Medicine before?

Yes

No

Main problem(s) you would like us to help you with: *

How long ago did this problem begin? Please be specific. *

To what extent does this problem interfere with your daily activities? *

What kinds of treatment have you tried? *

Your general health as a child was

Excellent

Good

Average

Poor

Surgeries (please include dates)

Significant trauma (motor vehicle collisions, falls, emotional, etc.)

Known or suspected allergies or sensitivities both internally and topically (drugs, chemicals, foods, scents, etc.) *

Acupuncture Health History