Meghan Meade Acupuncture - Health History
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Name
Date of Birth
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Primary Phone
Email
Occupation
Town You Live In
Referred By
Main Complaint You Would Like to Address
When Did this Issue Begin?
What Types of Therapies Have You Tried?
Medications Taken in the Past Two Months (vitamins, supplements, herbs, pharmaceuticals)
Significant Trauma (car accidents, hospitalizations, surgeries, etc)
Allergies
Please Briefly Describe Your Diet
Please Briefly Describe Your Activity Level (walking, yoga, running, strength training, etc)
Medical History
Please check any symptoms you've experienced in the past 3 months:
Current
Temperature
Skin & Hair
Head
Sleep
Cardiovascular
Respiratory
Gastrointestinal
Appetite
Urinary
Male Health
Female Health
Are you or is it possible that you are pregnant?
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Number of Pregnancies
Live Births
Miscarriages
Abortions
Are you currently using birth control?
Age at first period
Duration of period
Length of cycle
Cycle Symptoms
Musculoskeletal
Neurological
Emotions
Have you ever sought treatment for emotional or psychological health?
Have you ever considered or attempted suicide?
Do you have any questions for me?
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