Workplace acupuncture — Holly Peyton-Smith

Workplace Wellness
Intake Form

Well done! You’ve decided to partake in some educational and therapeutic workplace wellness. The information gathered below is crucial in order for your therapist to perform the best possible session for you. Each treatment is tailored to your specific needs, so please fill out as much as possible. If you have any particular requests or notes, there is a blank section at the bottom. Your information is completely confidential and will not be disclosed outside of your session without consent.

Name

First Name

Last Name

Phone

(###)

###

####

Date of birth

Gender and preferred pronouns (if applicable)

What is your main concern or health priority?

Medical history

Allergies

Medications and/ or supplements

Sleep

Digestion

Diet

Respiratory

Musculoskeletal

Mental health

Menstrual & sexual health

Acupuncture consultation and treatment

Acupuncture is considered a safe and gentle treatment with very few side effects, including but not limited to: bruising, minor bleeding, and discomfort. Sterile, single use needles are used in all treatments. You have the opportunity to discuss the nature of your treatment and any concerns or questions around the process. It is always advised to discuss any health concerns directly with your GP or primary physician.

Workplace Wellness
Intake Form

Naturopathy, Nutrition, Acupuncture, Cupping, Microneedling and skin aesthetics.

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Workplace Wellness Intake Form

Naturopathy, Nutrition, Acupuncture, Cupping, Microneedling and skin aesthetics.

Sign up for the newsletter

Workplace Wellness
Intake Form