New Patient Information
Please answer the following questions as completely as possible before your first visit to Stone Guardian.
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Email *
Legal Name (First and Last) *
Preferred Name
Date of Birth *
MM
/
DD
/
YYYY
Height (Feet, inches) *
Weight (Pounds) *
Sex *
Gender *
Address ( ex: 1234 Fake St NE) *
City, State, Zip *
Phone Number *
Emergency Contact (Name, Relation, Phone) *
Significant Health History (Please list any and all relevant hospitalizations, major trauma and chronic diseases with dates) *
Current Prescriptions (Please list any and all prescribed and/or recreational drugs, supplements and herbs taken on a regular basis) *
What is causing you to seek Acupuncture care? *
Do you have any body pain? *
If you answered yes, please describe your pain.
Do you suffer from headaches? *
Do you suffer from dizziness? *
How much water do you drink each day? *
How many hours of uninterrupted sleep do you normally get a night? *
Are you more likely to be too hot or too cold? *
Do you ever sweat without exertion? *
Please select any present eye conditions. *
Required
Do you ever get ringing in your ears? *
Do you ever notice your own heartbeat? *
Please describe your digestion. *
How many bowel movements do you have per day? *
How would you describe your thirst? *
How would you describe your hunger? *
How would you describe your present emotional state? *
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