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Occupation
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Can we email you updates and newsletters?
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Marital Status:
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Height
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Weight:
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Physician: (Name)
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(Phone)
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General Questions:
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Have you had acupuncture before?
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Chief Complaint:
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How long have you had this condition?
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Is it getting worse?
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Does it bother your:
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Other
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What seemed to be the initial cause?
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What seems to make it better?
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What seems to make it worse?
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Are you experiencing pain right now?
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Describe your pain:
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Other
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What makes your pain better?
• • •
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Body Diagram
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Family Medical History:
• • •
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Other
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Are you currently on any medications?
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If Yes, Please List:
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Do you take any vitamins/supplements?
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If Yes, Please List:
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Lifestyle:
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Do you consume Alcohol?
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# per day
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Do you have Stress?
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Do you use Marijuana?
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Do you use Tobacco?
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# per day
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Do you use Drugs?
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Do you have any Occupational Hazards?
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Do you exercise regularly?
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Type
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Frequency
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Type
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Frequency
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Your Past Medical History:
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Surgery (Please List All)
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Major Trauma:
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Other:
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General Symptoms:
• • •
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If bowel movements: Frequency per day?
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Infectious Diseases:
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Sweat easily(describe):
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Musculoskeletal:
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Other
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Woman Only: Gynecology
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Are you pregnant?
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Duration of flow
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Do you have Irregular Periods?
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Do you have Painful Periods?
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PMS?
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Vaginal Discharge (Color)
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Do you have Vaginal Sores?
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Do you have Vaginal Odor?
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Do you have Clots?
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Date Last Period began
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Length of cycle (Day 1 to Day 1)
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# Pregnancies
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# Live Births
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Premature Births
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Age at Menopause
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Please List Any Other Pertinent Information:
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