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Patient Intake Form CV19

Personal Info
Contact Info
Emergency Contact
Doctor
Other
Medical Info
Insurance Info
Conditions
Infectious
Health Questions
Treatment Goals
Energy Level
LU/LI (Metal)
Emotion / Memory
LIV/GB (Wood)
TMJ (Jaw)
Well Being
Male Health
KID/UB (Water)
Feet
Energy
Female Health
COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Oncology
Area of Complaint
Headaches
Neurological
Hearing
Cardiovascular
Kidney
Blood
Gastrointestinal
Reproductive
Immune
Skin
Musculoskeletal
Respiratory
Endocrine
Family History
Miscellaneous
Review and Accept