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Intake Form

Personal Information

Emergency Contact Information

Accident Info

Emotion / Mood

Energy Level

HT/SI (Fire)

KID/UB (Water)

LIV/GB (Wood)

LU/LI (Metal)

Oncology

Prenatal

SP/ST (Earth)

Vocal Health

Vocal History

Well Being

Brain Disorders

TMJ (Jaw)

Conditions

Area of Complaint

Headaches

Blood

Cardiovascular

Endocrine

Gastrointestinal

Hearing

Immune

Kidney

Musculoskeletal

Neurological

Reproductive

Respiratory

Skin

Miscellaneous

Additional Information

Summary