New Patient Intake Form
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BASIC INFORMATION: 
First Name: *
Last Name: *
Date: *
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Date of Birth: *
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Age: *
Address *
Contact Number *
Email:
Martial status: 
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Height: *
Weight: *
Allergies:  *
Emergency Contact Name: *
Emergency Contact phone number: *
Emergency Contact Relationship:  *
Physician (Name): *
Physician phone number:
GENERAL QUESTIONS:
Have you had acupuncture before?  *
Required
Chief Complaint:  *
How long have you had this condition?  *
What seemed to be the initial cause?  *
What seems to make it better?  *
What seems to make it worse? 
Are you experiencing pain right now?  *
Required
FAMILY MEDICAL HISTORY: 
Conditions:  *
Required
MEDICATION HISTORY: 
Are you currently on any medications?  *
Do you take any vitamins/supplements?  *
LIFESTYLE: 
Alcohol per day # 
Tobacco per day # 
Regular Exercise: 
PAST MEDICAL HISTORY: 
Check any of the following conditions you currently have or have had in the past:  *
Required
Have you had any surgery done? 
GENERAL SYMPTOMS: 
Please check all that apply:  *
Required
MUSCULOSKELETAL: 
Check all that apply:  *
Required
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