Facial Rejuvenation Forms

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Acupuncture Center, Inc. Balanced Meridian Acupuncture and Herbals Michele M. Arnold, L.Ac., Dipl. Ac. & C.H. 15644 Pomerado Road, Suite 304 Poway, CA 92064 (858)-613-0792 www.balancedmeridian.com This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. Please fill it out as completely as possible even if you do not feel certain questions pertain to your present condition. Thank you.
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Health History

Please indicate if any of the following pertain to you: (marking “yes” does not make you ineligible for treatment, however, it may restrict some of our treatment modalities):











Your Goals and Expectations










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