Intake Form

Required Field
Personal Info
Contact Info
Emergency Contact
Doctor
Other
Medical Info
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Insurance Info
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Conditions
LU/LI (Metal)
SP/ST (Earth)
Energy Level
KID/UB (Water)
LIV/GB (Wood)
HT/SI (Fire)
TMJ (Jaw)
Acupuncture
Emotion / Memory
Energy
Female Health
Oncology
Area of Complaint
Brain Disorders
Headaches
Neurological
Hearing
Blood
Gastrointestinal
Kidney
Skin
Reproductive
Immune
Cardiovascular
Respiratory
Musculoskeletal
Endocrine
Family History
Miscellaneous
Eating Habits
Prenatal (check boxes to enter details below)
Emotion / Mood
Review & Agree