Sun and Moon Acupuncture in San Jose, CA

Health Survey

Please fill out the information below to determine how we can best meet your needs.
The initial half-hour consultation is free.

Name:

Address:

City:

State:

Zip:

Phone (Home):

Phone (Work):

Email:

Occupation:

# Hours per week currently working:

Spouse Occupation:

# Hours per week currently working:

1	Check off any of the following symptoms you have experienced in the past six months.

Headaches / Migranes

Allergies

Fatigue

Weight Trouble

Pain / Tension / Numbness

	Neck	Legs
	Shoulders	Arms
	Low Back	Hands

Digestive Trouble

	Gas	Constipation
	Bloating	Diarrhea

Irritability

Menstrual Problems

Nervousness

Ringing in Ears

Dizziness

Asthma

Bladder Trouble

Sinus Problems

Insomnia / Sleep problems

Other:

2	Does this cause you to be?

3	Does this affect your work?

4	Does this affect your life?

	Moody
	Irritable
	Interrupt Sleep
	Restricted on daily activities

	Decision Making
	Poor Attitude
	Decreased Productivity
	Exhausted at End of Day
	Unable to Work Long Hours

	Lose Patience with Spouse or Children
	Restricted Household Duties
	Hinders Ability to Excercise or Participate in Sports
	Interferes with Ability to Participate in Hobbies or Other Desired Activities

5	There are several alternatives available to you. Please check the item most appriopriate for you.

Before making an appointment, I would like the Doctor to call me to discuss my health problems

I would like to come to the Doctor's office for a complete evaluation. This will allow me to find out if I can be helped by Acupunture without any financial barriers

If possible, I'd like to see the doctor on:
If that time is not available, then at: