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Consultation Form

The community clinic is very busy but also a very calm space. To help with time management, it would be really helpful if you could fill out the online consultation form before you attend your appointment. Please share as much information as possible, as this is essential for diagnosis and treatment, allowing more time to discuss your health. It also means you benefit from a longer treatment. 

*Acupuncture is a safe method of treatment, but on extremely rare occasions, it may induce minor bleeding, bruising, numbness, or tingling near the needling sites, dizziness, and fainting; these rare side effects do not impose any risks or danger to a patient’s health or life.

Please contact Health Tree Acupuncture acupuncturist John if you have any questions or concerns you may have before your first treatment.

Fertility Acupuncture Consultation Form

Birthday
Day
Month
Year
Have you had acupuncture before?
Yes
No
Are you currently under the care of a healthcare provider? If yes please provide details:
Yes
No

Allergies

Reproductive Health

Menstrual History

Is your cycle regular?
Yes
No

Lifestyle and General Health

Do you smoke?
Yes
No

Stress and Emotional Wellbeing

Ho would you rate your stress level?
Do you have any significant emotional or psychological challenges?
Yes
No
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