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Review Information

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Patient Medical History

Name:
Date:
Address:
City: ,
Phone (Home):
Phone (Cell):
Age:
Date of Birth:
E-mail:
Occupation:

Gender:
Are you pregnant?
How many weeks?

Emergency Contact:
Emergency Contact Phone:
Primary Physician:

How did you hear about us?
What is the best way to communicate with you between office visits? (E-mail, Home, Work, Cell, Text):

Have you ever had Acupuncture before:
Are you interested in a treatment plan:

Chief Complaint

What is your main issue that you would like to address:
How long ago did this problem begin:
Have you been given any MD’s diagnosis? If so, what?
What kind of treatments have you had? Results?

Secondary Complaint

Significant Illnesses:
Other:

Major Operations and approximate dates:
Allergies:
Accidents/Significant Trauma:
Current medications taken (including drugs, vitamins, herbs & supplements):

System Review:

GENERAL:
Please check all that apply:
Other unusual or abnormal conditions you have noticed in your general sense of health:

SKIN & HAIR:
Please check all that apply:
Any other hair or skin problems:

HEAD, EYES, EARS, NOSE, THROAT:
Please check all that apply:
Any other head of neck problems:

CARDIOVASCULAR:
Please check all that apply:
Any other heart or blood vessel problems:

RESPIRATORY:
Please check all that apply:
Any other lung problems:

GASTROINTESTINAL:
Please check all that apply:
Any other problems with stomach or intestines:

GENITOURINARY:
Please check all that apply:
Do you wake up at night to urinate?
If yes, how often?

Any particular color to your urine?
Any other genital or urinary problems

REPRODUCTIVE AND GYNECOLOGIC:
Please check all that apply:
The day of last menses:

MUSCULOSKELETAL:
Please check all that apply:
Any other joint or bone problems:

NEUROPSYCHOLOGICAL:
Please check all that apply:
Have you ever been treated for emotional problems?
Have you ever considered or attempted suicide?
Any other neurological or psychological problems?
Comments:

Please check any items that apply to you:
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I consent to having treatments and procedures from this clinic. I release Dr. Tony Willcox PhD. and Acupuncture Zen Inc and its staff from any all claims incurred to me as a result of treatment.

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Timestamp

Audit

December 3, 2020 1:09 pm EDT

Review Information Uploaded by Dr. Tony Willcox - [email protected] IP 103.109.97.153