Acupuncture

Book Your Traditional Chinese Medicine Discovery Call

First Name *

Last Name *

Email *

Phone *

Date of Birth *

Describe your diet. Please be specific - list breakfast, lunch, dinner, and snacks, as well as the times you eat.

What is your main health complaint? *

How often does it bother you? *

Every day

Once per week

2 to 3 times per week

Once per month

How long has it been happening? *

1-6 months

1-3 years

Over 3 years

What have you tried so far that has or has not worked? *

What (or who) would prevent you from completing a health-rebuilding or weight loss program? *

Please list any medications and supplements you take and the reason. *

What are 5 things you LOVE about your life? *

What would you like your health to be 3 months from now? 6 months from now?

What do you hope to achieve through our work together? *

Where did you hear about us? *

Google / Online search

Referral from friend or family member (please specify below)

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Institute of Functional Medicine

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If you selected "other," please specify:

I want to get awesome health tips, tools and resources to my inbox! *

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