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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!

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 Anxiety daily?
9. Do you have a health insurance plan?
Or Upload Front of Ins. card
Max File Size 15MB
Uplad Back of Ins. card
Max File Size 15MB
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!

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