Clinical Intake

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Personal Info
Contact Info
Emergency Contact
Doctor
Other
Medical Info
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Insurance Info
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Conditions
Health Questions
Male Health
Feet
KID/UB (Water)
Energy Level
HT/SI (Fire)
LIV/GB (Wood)
TMJ (Jaw)
SP/ST (Earth)
LU/LI (Metal)
Treatment Goals
Emotion / Memory
Well Being
Acupuncture
Female Health
Energy
Genetics
Infectious
COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Vocal Health
Oncology
Vocal History
Area of Complaint
Brain Disorders
Headaches
Musculoskeletal
Gastrointestinal
Neurological
Cardiovascular
Skin
Hearing
Blood
Kidney
Reproductive
Immune
Respiratory
Family History
Endocrine
General Injury Related Questions
Miscellaneous
Eating Habits
Prenatal (check boxes to enter details below)
Postpartum (check boxes to enter details below)
Massage Goals
Accident Info
Which best describes what you are experiencing
Current Complaint
Physical Activities You Participate In
Number of Times of Week You Practice
Allergy
Emotion / Mood