Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Past or Current Medical Problems *

Please tick all that apply and / or use the text box below

Implants / Pacemaker

Epilepsy

Contagious Disease

Cardio Vascular disease

Cancer

Have you ever had radiation/chemotherapy

Spinal Injuries

Stress/Depression

Osteoporosis

Rheumatism/arthritis

Asthma/ Lung condition

Diabetes

Liver/Kidney problems

Haemophilia

Have you or any family member had skin cancer

Neurological disorder

Hayfever

None of the above

Medication *

Please specify any regular medication including supplements or oral contraceptive pill

Yes

No

Allergies *

Medications / Food / Latex / Environmental (dust, pollen etc)

Yes

No

I hereby understand that Acupuncture maybe contra-indicated for certain conditions and therefore I have fully disclosed my full medical history to my practitioner. *

I understand

I don't understand