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Fiona Li, LAc, DACM, LMT, Dipl.O.M.
Joshua Lipsman, MD, MPH
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Home
Services
Acupuncture
Joint Pain Relief
Chiropractic Care
Physical Rehab
Back Pain
Neck Pain/Migraines
Shoulder Pain Relief
Trigger Point Injections
Knee Pain Relief
Sports Medicine
Physical Therapy
Sciatica
Providers
Fiona Li, LAc, DACM, LMT, Dipl.O.M.
Joshua Lipsman, MD, MPH
Ben Gruen, DC
Blog
About
Contact
Patient Intake Form
Menu
Home
Services
Acupuncture
Joint Pain Relief
Chiropractic Care
Physical Rehab
Back Pain
Neck Pain/Migraines
Shoulder Pain Relief
Trigger Point Injections
Knee Pain Relief
Sports Medicine
Physical Therapy
Sciatica
Providers
Fiona Li, LAc, DACM, LMT, Dipl.O.M.
Joshua Lipsman, MD, MPH
Ben Gruen, DC
Blog
About
Contact
Patient Intake Form
Patient Intake Form
First Name
Last Name
Date of Birth
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Female
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ID#
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Google
Zocdoc
Friend / Family member refers
Other
Occupation and weekly hours you work
Emergency Contact’s Name:
Emergency Contact's Phone:
Have you had acupuncture before:
Yes
No
Have you had chiropractic before:
Yes
No
Have you had physical therapy before:
Yes
No
Are you currently pregnant?
Yes
No
Not Sure
HIV positive?
Yes
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Not Sure
Hepatitis Positive?
Yes
No
Not Sure
Chief Complain 1
Neck pain
Jaw pain/tightness (TMJ)
Shoulder pain
Arm pain
Elbow pain
Wrist pain
Hand (joint) pain
Upper back pain
Middle back pain
Lower back pain
Tailbone pain
Hip pain
Knee pain
Leg pain
Ankle pain
Foot pain
Heel pain
Swelling / Edema
Insomnia
Tiredness / Fatigue
Anxiety / Depression
Headache / Migraine
Dizziness
Bell's Palsy
Acne
Constipation
Nausea and Vomiting
Digestive disorders
Weight management
Irregular menstrual cycle
Menstrual pain
Infertility
Women’s health
Menstrual treatment
Hormonal inbalance
Chief Complain 2
Neck pain
Jaw pain/tightness (TMJ)
Shoulder pain
Arm pain
Elbow pain
Wrist pain
Hand (joint) pain
Upper back pain
Middle back pain
Lower back pain
Tailbone pain
Hip pain
Knee pain
Leg pain
Ankle pain
Foot pain
Heel pain
Swelling / Edema
Insomnia
Tiredness / Fatigue
Anxiety / Depression
Headache / Migraine
Dizziness
Bell's Palsy
Acne
Constipation
Nausea and Vomiting
Digestive disorders
Weight management
Irregular menstrual cycle
Menstrual pain
Infertility
Women’s health
Menstrual treatment
Hormonal inbalance
Chief Complain 3
Neck pain
Jaw pain/tightness (TMJ)
Shoulder pain
Arm pain
Elbow pain
Wrist pain
Hand (joint) pain
Upper back pain
Middle back pain
Lower back pain
Tailbone pain
Hip pain
Knee pain
Leg pain
Ankle pain
Foot pain
Heel pain
Swelling / Edema
Insomnia
Tiredness / Fatigue
Anxiety / Depression
Headache / Migraine
Dizziness
Bell's Palsy
Acne
Constipation
Nausea and Vomiting
Digestive disorders
Weight management
Irregular menstrual cycle
Menstrual pain
Infertility
Women’s health
Menstrual treatment
Hormonal inbalance
Complaints are not listed above(if any)
Past Medical History
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