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Intake Form

Personal Information

Emergency Contact Information

Doctor Information

Insurance Information

Acupuncture

Eating Habits

Emotion / Memory

Emotion / Mood

Energy

Energy Level

Feet

Female Health

HT/SI (Fire)

KID/UB (Water)

LIV/GB (Wood)

LU/LI (Metal)

Oncology

Prenatal

SP/ST (Earth)

Well Being

TMJ (Jaw)

Conditions

Area of Complaint

Headaches

Cardiovascular

Endocrine

Family History

Gastrointestinal

Hearing

Immune

Musculoskeletal

Neurological

Reproductive

Respiratory

Skin

Miscellaneous

Additional Information

Summary

Antares Wellness - Revised Clinic Policies click to view

Consent for Undraping the Chest click to view