New Patient Intake Form

Welcome to

DallasAcuClinic

Our questionnaire is designed to help figure out which service(s) will be right for you. Please take a moment to let us know how we can help. Once complete, proceed to making an appointment.

DallasAcuClinic is excited to be part of your Wellness!

Contact Info

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Full Name *

Phone Number *

Email Address *

Nervous System

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anxietyvertigomigrainesblurred visionLoss of smellLoss of tasteringing in earsdepressionlack of focusfatiguesleeplessnessprocrastinationmemory losslight sensitivityseizuressound sensitivityPTSDirritabilitypast emotional abuseother

Muscle Skeletal

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neck painelbow rhip rfoot rmid-back painwrist lknee lhead feels heavylow-back painwrist rknee rlimited motionshhoulder lhand lankle lswollen jointsshhoulder rhand rankle rloss of grip/strenght/otherelbow lhip lfoot l

Reproductive / Endocrine

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night sweatshormonal imbalancedifficulty conceivingdifficulty w/body sexual performancedifficulty w/body regulationweaknesselevated blood sugarlow blood sugar

GI / Excretory / Immune

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indigestionoverweightunderweightbloatingconstipationdiarrheafood allergiesabdominal painfrequent urinationpainful urinationblood/mucus in stoolblood mucus in urinelack of bladder controlhemorrhoidsfrequent colds/flu/sicknessother

Skin

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acneabnormal pigmentationdrynessitchy patchesgeneral itchinessrednessred patchescracked skinoily skinpale skin

Any other symptoms you want to tell us about?

After you click Submit, please proceed to making your appointment!

Submit

Business Hours :

Monday - Friday: 09 am - 6 pm

Sat. - Sun.: 10 am - 5 pm

Contact :

(469) 867-1841

DallasAcuClinic@gmail

Make An Appointment

Address :

6211 W Northwest Highway
Suite C260, Dallas, TX, 75225

Make An Appointment

6211 W Northwest Highway Suite C260, Dallas, TX, 75225