DM Acupuncture
Patient Intake Form
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Emergency Contact
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Claims / Benefit
Conditions
Health Questions
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Cardiovascular
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Pacemaker
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Concussion
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Asthma
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TMJ (Jaw)
Jaw Pain
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Difficulty Opening Jaw
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Locking
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Ear Ringing
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Jaw Pain
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Clenching
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Locking
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Clicking
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Difficulty Opening Jaw
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Ear Ringing
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Clenching
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Grinding
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Clicking
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Male Health
History of STD
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Painful Ejaculation
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Difficulty Maintaining Erection
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History of STD
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Painful Ejaculation
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Difficulty Maintaining Erection
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Female Health
Menopause
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Severe Menstrual Pain
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Menopause
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Severe Menstrual Pain
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Breast Cancer
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Breast Cancer
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Ovarian Cancer
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Ovarian Cancer
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Currently Pregnant
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Currently Pregnant
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PCOS
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PCOS
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Pelvic Pain
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Pelvic Pain
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Oncology
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Date of Diagnosis
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Location
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Location
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Status
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Status
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Lymph Nodes Removed
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Lymph Nodes Removed
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Treatment: Chemotherapy
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Treatment: Chemotherapy
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Side Effects of Chemo
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Side Effects of Chemo
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Medical Devices
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Medical Devices
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Pain
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Pain
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Reproductive
Ovarian Cysts/Tumors
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Pelvic Inflammatory Disease
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Premenstrual Syndrome
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Breast Disorder
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Uterine Disorder
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Pregnancy
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Ectopic Pregnancy
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Gynaecological Conditions
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Endometriosis
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Menopause
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Menstrual Cycle Disorder
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Immune
Non-Hodgkin Lymphoma
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Rheumatoid Arthritis
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Anaphylaxis
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Allergies
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Lupus
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Hodgkin Lymphoma
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Cancer
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Infectious Mononucleosis
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Leukemia
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Respiratory
Chronic Cough
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Shortness of Breath
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Respiratory Conditions
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Tuberculosis
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Asthma
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Emphysema
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Respiratory Tract Infection
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Bronchitis
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COPD
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Cystic Fibrosis
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Infectious Respiratory Conditions
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