Meghan Meade Acupuncture - Health History
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Name
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Date of Birth
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Primary Phone
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Email
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Occupation
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Town You Live In
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Referred By
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Main Complaint You Would Like to Address
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When Did this Issue Begin?
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What Types of Therapies Have You Tried?
Medications Taken in the Past Two Months (vitamins, supplements, herbs, pharmaceuticals)
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Significant Trauma (car accidents, hospitalizations, surgeries, etc)
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Allergies
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Please Briefly Describe Your Diet
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Please Briefly Describe Your Activity Level (walking, yoga, running, strength training, etc)
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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?
Number of Pregnancies
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Live Births
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Miscarriages
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Abortions
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Are you currently using birth control?
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Age at first period
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Duration of period
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Length of cycle
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Cycle Symptoms
Musculoskeletal
Neurological
Emotions
Have you ever sought treatment for emotional or psychological health?
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Have you ever considered or attempted suicide?
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Do you have any questions for me?
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