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Intake Form

Please fill in this form prior to your appointment so that we can get started as soon as you arrive.

Name*

Date of birth*

Age

Gender

Address*

Home Phone

Mobile Phone

Email Address

Occupation

Have you had Acupuncture before?

How did you hear about us?

Emergency Contact

Relationship To You

Phone Number

What Is The Reason For Your Visit (Please list main complaint.)*

Is there anything that improves or aggravates your main issue?

Additional health concern & approximate date of onset

Additional health concern & approximate date of onset

Additional health concern & approximate date of onset

Are you under a physician’s care for any of your health concerns? (please describe)

Date of last physical exam

Physician's name

Please list any hospitalizations and/or surgeries

Please check all that apply

Please list prescription or over the counter drugs you are currently taking, dosage, what purpose, and date you began taking

Please list vitamins, minerals, and supplements you are currently taking, dosage, what purpose, and date you began taking

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