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Patient Intake Form

Personal Information

Acupuncture

Emotion / Memory

Emotion / Mood

Energy

LIV/GB (Wood)

Prenatal

Well Being

TMJ (Jaw)

Conditions

Area of Complaint

Headaches

Blood

Cardiovascular

Endocrine

Family History

Immune

Kidney

Musculoskeletal

Neurological

Reproductive

Respiratory

Skin

Miscellaneous

Additional Information

Patient Summary