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Patient Intake Form

Personal Information

Emergency Contact Information

Doctor Information

Insurance Information

Eating Habits

Emotion / Mood

Energy

HT/SI (Fire)

KID/UB (Water)

LIV/GB (Wood)

LU/LI (Metal)

SP/ST (Earth)

Well Being

Brain Disorders

Conditions

Area of Complaint

Headaches

Cardiovascular

Endocrine

Family History

Gastrointestinal

Hearing

Immune

Kidney

Musculoskeletal

Neurological

Reproductive

Respiratory

Skin

Miscellaneous

Additional Information

Patient Summary