Acupuncture Intake Form
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3Acupuncture Intake Form
Personal Information
Patient Name:
Age:
Birth Date:____/____/____
Gender:
Address:
City:
State:
Zip:
Telephone (Day):
Telephone (Night):
Telephone (Mobile):
Email Address:
Occupation:
Referral Source:
Who is your primary heath care provider/MD?
Emergency Contact:
Phone:
Main Complaint
Please identify your major health concerns
1.
How long have you had this problem?
2.
How long have you had this problem?
3.
• How long have you had this problem?
• Have you been given a diagnosis for these problems?
• What other treatments have you tried and what were the outcomes?
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Parent category: Business