top of page

Thank you for considering your Acupuncture treatment at AcupunctureX @ Rapha Clinic

Please complete the following questionnaire to effectively and efficiently offer and schedule your First appointment with us!

1. What is the Main Reason, Symptoms and/or Condition? (check all that apply)
2. What is the intensity of your current condition (0 - 10)?
3. When was your most recent Acupuncture treatment?
4. What is your current Stress level (0 - 10)?
5. How long does it take to fall asleep at night?
6. How is your Quality of your Sleep at night? Do you wake up middle of your sleep at night?
7. Do you have Depressed mood daily?
8. Do you feel Anxious daily?
9. Do you have a health insurance plan?
Or Upload Front of Ins. card
Uplad Back of Ins. card
10. Where is your Preferred Location for your Acupuncture treatment? (check all that apply)
11. When is your preferred days and times for your Acupuncture treatment? (check all that apply)

Thanks for submitting!

bottom of page