Shopping CartYour Cart is EmptyQuantity: RemoveSubtotalTaxesShippingTotalThere was an error with PayPalClick here to try againThank you for your business!You should be receiving an order confirmation from Paypal shortly.Exit Shopping Cart Sage Living Acupuncture Chester NY WIse Care For A Healthy Body & Mind 914.438.3371 Intake Form Please fill in this form prior to your appointment so that we can get started as soon as you arrive. Name*Date of birth*AgeGenderAddress*Home PhoneMobile PhoneEmail AddressOccupationHave you had Acupuncture before?How did you hear about us?Emergency ContactRelationship To YouPhone NumberWhat Is The Reason For Your Visit (Please list main complaint.)*Is there anything that improves or aggravates your main issue?Additional health concern & approximate date of onsetAdditional health concern & approximate date of onsetAdditional health concern & approximate date of onsetAre you under a physician’s care for any of your health concerns? (please describe)Date of last physical examPhysician's namePlease list any hospitalizations and/or surgeriesPlease check all that applyDiabetesHigh Blood PressureHeart DiseaseHigh CholesterolCancerHIVHepatitisAsthmaAnemiaAutoimmune DisorderSeizuresAllergiesArthritisAnxiety/DepressionIrritable BowelAcid RefluxPlease list prescription or over the counter drugs you are currently taking, dosage, what purpose, and date you began takingPlease list vitamins, minerals, and supplements you are currently taking, dosage, what purpose, and date you began takingThis site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.SUBMITThank you! Your intake form was sent successfully.Toggle NavigationHomeFertilityOther Ailments & TreatmentsYour AcupuncturistTestimonialsOur OfficeForms & DocumentsContact UsHomeFertilityOther Ailments & TreatmentsYour AcupuncturistTestimonialsOur OfficeForms & DocumentsContact Us / PreviousNextPausePlayClose
