Free Acupuncture Consultation - The Women's Acupuncture Center serving Women in Maryland

Does this cause you to be?

Moody
Depressed
Irritable

Sleeping with Interruptions
Restrict Daily Activities

Does this affect your work?

Decision Making
Poor Attitude
Decreased Productivity

Exhausted at end of day
Unable to work long hours

Does this affect your life?

Lose patience with spouse or children
Hinders ability to participate in hobbies or other desired activities

Restricted household duties
Hinders ability to exercise or participate in sports

Free Acupuncture Consultation

This information is confidential and will be used solely for purposes of diagnosis and treatment. It will not be shared with or distributed to any outside sources.

Upon submission of this survey, you will be contacted within
five business days to set up your free, in-person consultation.

Please Complete The Form Below - Items Marked with an * are required

Full Name: *		Age:
Home Phone:*	- (Area Code)	Work Phone:	- (Area Code)

Email *

Address: *

City: *

State *

Zip: *

Occupation: *

Hours per week currently working: *

Spouse Occupation:

Hours per week currently working:

County you work in:

How did you hear about us?

From a friend
Attended a presentation
Online Search
Other

Check off any of the following symptoms you have experienced in the last 6 months:
	Headaches/Tension Fatigue/Tired Pain Anywhere in the Body Digestive Disturbance/Bloating IBS/Constipation Stress (Mental/Emotional/Physical) Urinary Problems Heart Palpitations GERD/Heartburn Difficulty Sleeping Irritability/Mood Swings Depression/Anxiety Neck Pain Wrist/Hand Pain Shoulder or Elbow Pain Hip or Knee Pain Breast Tenderness	Ankle/Foot Pain Edema/Swelling Ringing in Ears Nervousness Loss of Sex Drive Allergies Frequent Colds Night Sweats Menstrual Problems Hot Flashes Fertility Issues PMS/Cramps Numbness/Tingling in Arms/Hands/Legs/Feet Pain/Tension Across Top of Shoulders Low Back Pain Low Thyroid Weight Trouble Hair Loss

Which of the above bothers you the most? *
How long have you been bothered by the condition? *
Describe how it feels or affects you when it is at it's worst: *

	I would like to come to The Women's Acupuncture Center for an initial evaluation and consultation. There is NO CHARGE for this and will allow me to find out if I can be helped by Acupuncture without any financial barriers. I would like to come for further wellness classes. I would like to receive the monthly Women's Wisdom email to help me connect with feminine energy and power.
	Please enter the code as shown:

The Women's Acupuncture Center | 5005 Signal Bell Lane, Suite 102, Clarksville, MD 21029 | (410) 207 - 3476