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About Acupuncture TCM
About Acupuncture / TCM
Evidence Base for Acupuncture
Western Named Conditions
Patient Feedback Form
Patient Feedback Form
Your Name
(Required)
What was the problem or problems that you had acupuncture treatment for?
(Required)
Thinking back to when you started treatment, how bad was the problem on a scale from 1 (not so bad) to 10 (unbearable)?
(Required)
Please enter a number from
1
to
10
.
Thinking back, how often would you have this problem? From 1 (rarely) to 10 (ALL the time)?
(Required)
Please enter a number from
1
to
10
.
Did you take medication to manage the problem?
(Required)
Yes, I took medication
No, I did not take medication
What medication did you take?
How often did you take the medication?
How much did you take?
Think about how the same problem is now. On a scale from 1 to 10, how bad is it now?
(Required)
Please enter a number from
1
to
10
.
At the moment, how often do you have this problem? From 1 (rarely) to 10 (ALL the time)?
(Required)
Please enter a number from
1
to
10
.
At the moment, do you take medication to manage the problem?
(Required)
Yes, I am taking medication
No, I am not taking medication
What medication are you taking?
How often do you take it?
How much do you take?
Did you experience any change in your symptoms since receiving treatment?
(Required)
Yes, much improvement
Yes, a little improvement
Neither improved nor worsened
Yes, a little worse
Yes, much worse
Please describe the change you experienced.
Do you feel this change in your symptoms was due to the acupuncture treatment you received?
(Required)
Yes, definitely
Yes, possibly
No, I don't feel it's related
Did you benefit from treatment in other ways? If so, how?
Is there anything else you would like to mention?
Do you consent to your feedback being shared anonymously within the participating practices who provide the Acupuncture clinic?
Yes, I consent.
No, I don't consent.
Do you consent to your feedback being shared with your GP?
Yes, I consent.
No, I don't consent.
Can we contact you for further information about your acupuncture treatment?
Yes
No
Do you prefer to be contacted by Email or Phone?
Email
Phone
What is your email address or phone number
Name
This field is for validation purposes and should be left unchanged.
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