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Health History
You careful answers to these question are very important to a proper diagnosis is Chinese Medicine, your attention to these questions is greatly appreciated. The Form is powered by G Suite and is HIPAA compliant.
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Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Middle Initial
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Home Address: street ,town, and zip code
*
Your answer
If you are a minor, please write your guardians name and phone number here:
Your answer
Cell phone number
*
Your answer
Health Insurance Company (I only direct bill BCBS)
*
BCBS
Harvard Pilgrim
I do not have insurance
Other:
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This form was created inside of Jeff Shih-chung Matrician, Licensed Acupuncturist.
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