Cosmetic Acupuncture and Facial Cupping Intake Form

Date of birth*

Name*

First Last

Phone*

Please provide us with the phone number for which you are most easily reached.

Email*

How did you hear about us?*

Referral

If you have been referred, please let us know by whom so we can thank them.

Have you had acupuncture before?

Yes
No

Occupation

Your Health

If yes, please specify.

Have you had any health problems in the past or present?*

Yes
No

If yes, please specify.

List any medications, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly.*

Do you have any allergies?*

Yes
No

If yes, please specify.

Do you any problems with bleeding or bruising?

Yes
No

Do you follow a restricted diet?

Yes
No

If yes, please specify your restrictions.

Do you smoke?

Yes
No

On average how much water do you consume daily?

On average how many alcoholic beverages do you consume weekly?

On average how many caffeinated beverages do you consume daily? (coffee, tea, soft drinks)

Do you exercise regularly?

Yes
No

If yes, please specify how many times per week.

Do you wear contact lenses?

Yes
No

Do you sunbathe or use tanning beds?

Yes
No

If yes, how often?

Have you experienced claustrophobia?

Yes
No

Within the last 9 months have you been undergone surgery?

Yes
No

What is your pain threshold?

1 being quite low and 5 being quite high.

Please enter a number from 1 to 5.

What massage pressure do you prefer?

Light
Medium
Firm

Your Skin

Check off all the specific skin concerns/ challenges that apply.

fine lines
wrinkles
redness
brown spots
loss of firmness
acne
other

Please share any further details regarding your goals for your visit.

What skin care products are you currently using?

Other makeup:

Body products

bar soap
shower gel
scrubs
oil
body moisturizer
depilatory products
self-tanner

Do you use facial tools? eg: gua sha, facial rollers, microneedler, nuface, cleansing brush etc.

Yes
No

If yes, please specify which and how often:

Have you ever had:

chemical peel
microdermabrasion
laser
intense pulsed light
dermaplaning
microneedling

If yes, please specify which and when you last received this treatment.

Do you use: Retin-A, Renova, Adapalene or any other prescription skin products?*

Yes
No

If yes, was it in the last 3 months?

Yes
No

Are you currently using products that contain any of the following ingredients?

hydroxy acids (glycolic, lactic, salicylic etc.)
exfoliating scrubs
vitamin A derivatives (Retinol, Retin-A, Retinyl Palmitate)

Do you ever experience these conditions on your skin?

flakiness
tightness
obvious dryness

Do you use sunscreen daily?

Yes
No

If yes, please specify what SPF you use for both face and body.

Choose which best describes your skin’s response to the sun.

always burns, blisters and peels
often burns, blisters and peels
burns moderately
burns rarely, if at all
never burns

Have you ever been diagnosed with melasma?

CALL (778) 228-4275

Cosmetic Acupuncture and Facial Cupping Intake Form

Cosmetic Acupuncture Form

Cosmetic Acupuncture and Facial Cupping Intake Form

Your Health

Your Skin