Intake Form

Required Field
Personal Info
Contact Info
Emergency Contact
Doctor
Other
Medical Info
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Insurance Info
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Conditions
LU/LI (Metal)
SP/ST (Earth)
KID/UB (Water)
LIV/GB (Wood)
HT/SI (Fire)
Energy Level
Well Being
Energy
Emotion / Memory
Acupuncture
Oncology
Female Health
Vocal Health
Area of Complaint
Brain Disorders
Headaches
Cardiovascular
Blood
Musculoskeletal
Gastrointestinal
Immune
Neurological
Skin
Hearing
Kidney
Reproductive
Respiratory
Endocrine
Family History
Miscellaneous
Eating Habits
Emotion / Mood