Health History & Medications

Thank you for choosing Healing InSight! We’re delighted to work with you to help you feel better, look younger and love life.

Please thoughtfully answer these questions so we’re able to develop an individualized diagnosis and treatment plan that’s right for you.

Name:*

Preferred Name:*

Address:*

City:*

State:*

Zip:*

Cell Phone:*

Home Phone:

Work Phone:

E mail Address:*

example@example.com

Would you like to join Healing InSight's email list and stay up-to-date on specials and holistic health topics?

YesNoI'm already on it!

Date of Birth:*

Date

Age:

Weight:

Height:

Gender:

Marital Status:

Employer:

Occupation:

Emergency Contact:*

Emergency Contact Phone:*

How did you hear about us?

If you heard about us from someone, please share their name so we can thank them:

Have you ever received acupuncture before?

Do you have a Flex Spending Account (FSA)?

YesNo

Do you have a Healthcare Savings Account (HSA)?

YesNo

Payment is due on the day of your appointment. Receipts for insurance & healthcare/flex spending accounts reimbursements can be provided, please ask!

Please give us 24 hours advance notice if you need to cancel an appointment. You may be charged if you cancel an appointment without 24 hours notice.

Medical History