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About Acupuncture TCM
About Acupuncture / TCM
Evidence Base for Acupuncture
Western Named Conditions
Patient Feedback Form
Patient Feedback
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Your Name
What was the problem or problems that you had acupuncture treatment for?
Thinking back to when you started treatment, how bad was the problem on a scale from 1 (not so bad) to 10 (unbearable)?
0
Thinking back, how often would you have this problem? From 1 (rarely) to 10 (ALL the time)?
0
Did you take medication to manage the problem?
Yes
No
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?
0
At the moment, how often do you have this problem? From 1 (rarely) to 10 (ALL the time)?
0
At the moment, do you take medication to manage the problem?
Yes
No
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?
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?
Yes, definitely
Yes, possibly
No, I don't feel it's related
Is there anything else you would like to mention?
Did you benefit from treatment in other ways? If so, how?
Do you consent to your feedback being shared anonymously within the participating practices who provide the Acupuncture clinic?
Yes
No
Do you consent to your feedback being shared with your GP?
Yes
No
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
Email
Phone
Submit Form
