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New Member Intake

Personal Info
Contact Info
Emergency Contact
Doctor
Contact
Medications
Other
Primary Complaint
Primary Complaint
Location
Level of Discomfort (0=no pain, 10=worst pain imaginable)
No PainWorse Pain Imaginable
Describe Your Pain, Select all that Apply
Does your pain radiate?
Duration
When did your pain being?
Have you had this pain before?
Any previous treatment? If so, please select all that apply.
Aggravating Factors
Alleviating Factors
How well do you function with your pain?
Any Additional Complaints? (if applicable, please describe)
Additional Information
Current Health History
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TerriblePerfect
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Goals of Care
Injuries
Surgeries
Medical History
Head & Neck
Chest, Lung, Heart & Skin
Internal, Digestive & Miscellaneous
Gynecological (Females Only)
Family Health History
Is there anything else you would like Dr. Quast to know?
Are you open to Acupuncture as part of your treatment?
Review & Agree
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