Preparing your first consultation

To help me prepare for your first consultation and provide you with the best possible service, I ask that you complete the following form.

Please gather all documents first and submit the form with all the information, no later than 48 hours before your appointment.

Full name

Date of birth

City

Profession

Reason for consultation

Therapeutic practices

All my questions have been answered and I have been informed about Traditional Chinese Medicine (TCM) and acupuncture, as well as all the details regarding this procedure. I hereby authorize the performance of acupuncture and other procedures related to Traditional Chinese Medicine.

Diseases

Medication

Supplements

Smoker

Exams or blood tests results

If you have any blood tests results or other exams relevant to the consultation please upload them here.

Upload two photos of your tongue

One with your tongue sticking out and one with the tip of your tongue resting on the roof of your mouth (ideally on an empty stomach, before scraping your tongue and brushing your teeth).

How is your sleep?

How much water do you drink per day?

Breakfast

Dinner

Lunch

How do you feel after eating?

How is the consistency of your feces?

How many times do you defecate?

How long is your cycle?

Do you have severe pain during your period?

Do you experience any of these symptoms during your period?

During the day, is there an emotion you feel more?

How often do you exercise your body per week?