Intake Form

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Personal Info
Contact Info
Emergency Contact
Doctor
Other
Medical Info
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Conditions
Acupuncture
Emotion / Memory
TMJ (Jaw)
Energy
Vocal Health
Female Health
Area of Complaint
Headaches
Respiratory
Reproductive
Immune
Gastrointestinal
Musculoskeletal
Cardiovascular
Neurological
Skin
Blood
Family History
Kidney
Endocrine
Hearing
Miscellaneous
Prenatal (check boxes to enter details below)