Acupuncture Health Center · Patient Information
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Name *
 Date of Birth *
Sex *
Weight *
Height *
Marital Status(S/M/W/D) *
Spouse's Name
Social Security Number
Driver's License *
Home Address *
City *
State *
Zip Code *
Home Phone
Work Phone
Cell Phone *
E-mail *
Emergency Contact Name/Phone Number *
Business Name and Address
What brings you in today?
How did you heard about us?
Please select all that apply
Through friends
Search Engine
Date of Current Illness/Injury *
First Date of Similar Illness? *
Did any other doctor/s seen for this problem? *
Have you been hospitalized for this problem? If so, please indicate how many days have you been hospitalized in other column. *
Disposable and Sterilized needles are used in the acupuncture treatment. Normally it does not cause bleeding, occasionally may cause small bruise. Please initial your name here if you understand and accept treatment. *
If you have had any of the condition listed below before or during our treatment, please indicate. We are not responsible for any problems in treating a condition that is not mentioned here. *
Please indicate any other illness that not been listed below in OTHER
Are you pregnant now? When you desire to be pregnant in near future?
Do you have any allergic condition to medicine/food? *
Do you have any operation/s before? If so, please indicate in Other . *
Are you taking any medicine right now? Please indicate  the medicine in Other column. *
Do you want to provide your symptoms details? *
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