New Patient Intake Form
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4Metsuyan Wellness
301.828.8856
New Patient Intake Form
Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All of
your information is confidential. Please print clearly in ink.
IDENTIFICATION:
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Name: _____________________________________
Sex:
F
M
Date:______________
Address: ____________________________________
City: ___________
State: _______
Zip: ___________
Telephone: (Home)_________________________(Work)___________________ (Cell)_______________________
Date of Birth: __________________________ Age: ______ Email:______________________________________
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Single:
Married:
Partnered:
Separated:
Divorced:
Widowed:
Height:___________________ Weight: _______________ Occupation:___________________________________
Education: _____________________________________________________________________________________
Emergency Contact: __________________________________ Relationship: _______________________________
Emergency Contact's Telephone:________________________(Home) _________________________________(Cell)
Name of Physician*: ___________________________________ Physician's Telephone:________________________
Physician's Address:_______________________________________________________________________________
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Date of Last Physician Appointment:______________________ Date of Last Gynecology Exam: ______________
N/A
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Have you ever been treated with acupuncture before?
Yes
No
*No contact will be made to the physician without your permission.
Reason why coming for Acupuncture: ___________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Current symptoms or problems:________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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Parent category: Medical