Facial Rejuvenation Acupuncture Intake Form

Thank you for taking 10-15 minutes to complete your intake form before your appointment. This ensures that your scheduled time will be spent in session, and that Lyndsey can divine the best strategies to treat your unique constitution before you arrive. This complete health intake will ensure that along with treating your skin, Lyndsey will also be working to support your whole body wellness, addressing internally motivated factors while she enhances your external beauty. All forms are strictly confidential and seen only by Lyndsey Madden, L. Ac.

General
Name *
Name
Today's Date
Today's Date
Do you text?
Skin
Health
Do you have a pacemaker?
Emotional Health
Emotions (please check any that apply):
Are you currently suicidal?
What level of stress are you experiencing at the present time?
What are the causes or factors of your stress?
Sleep
Lifestyle
Activity level: (circle one)
Please indicate if you eat, drink or use the following:
Check all that apply
Do you smoke?
Family History
Please indicate “F” for Father, “M” for Mother, “S” for Siblings, “G” for Grandparents, “O” for Other relatives.
Feminine Health
Are you currently pregnant?
Please note that if you are currently pregnant, our traditional facial rejuvenation acupuncture is contraindicated. Please contact spa to discuss a custom treatment.