clientPregnancy Consultation Form Name * First Name Last Name Email * Home Address * DOB * Doctor's Name/Hospital's Name: * Your Due Date * MM DD YYYY Is this your first pregnancy? * YES NO What current medication are you on? * Reason for Visit? * What other therapies are you receiving? (if there is any) Have you ever had Acupuncture? * YES NO How long have you had symptoms for? * What improves or makes it worse? * Please tick the boxes any of the following conditions that applies to you: * Nausea Sinusitis Headache Heartburn Carpal Tunnel Leg Aches Oedema Itching Insomnia Anxiety Thrush Varicose Veins SPD Pain Pain in the Back Pain in the Shoulders Rib Pain Breech Presentation Others: * Please list down the other condition that you may have and also explain or expand some details about here on the box. I consent to receive Acupuncture and I understand that I may on occasion bruise or bleed locally at the site of the needle. * I AGREE By ticking this you are subscribing to my monthly newsletter offering you health tips I AGREE Thank you! We appreciate your interest in our services. We will get back to you as soon as possible.
