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Dodam Acupuncture
Intake
Intake
Intake Form
New Patient Intake Details
Your Name
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First Name
Last Name
Name you go by (if different from above)
First
Gender
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Female
Male
Prefer not to respond
Date of Birth
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MM slash DD slash YYYY
Occupation
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Address
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Street Address
Address Line 2
City
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Vermont
Virginia
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
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Email
Emergency Contact Person's Name
Emergency Contact's Phone
Have You Ever Had Acupuncture Before?
Yes
No
How did you hear about us?
Google
Our Client
Your Doctor
Other
Main Health Concern
What brings you in for acupuncture/Kibone Therapy, primarily?
(Required)
When did this start? How often the symptom(s) occur?
Does this affect your ability to work, sleep, or go to school?
On a scale from zero to 10 how much pain or discomfort does this cause you?
Secondary Health Concerns
What else would you like to see if acupuncture/Kibone Therapy can help?
When did this start? How often the symptom(s) occur?
Does this affect your ability to work, sleep, or go to school?
On a scale from zero to 10 how much pain or discomfort does this cause you?
Your Current Health Condition – Current medications, supplements, etc.
How is your sleep?
How is your digestion?
How are your bowels?
How is your stress level?
How is your mental and emotional health?
Are you being abused at home, school, work, or elsewhere?
Yes
No
I’m not sure
Would you like to be connected with helping resources?
Yes
No
Maybe later
What is the most secure way we can give you info on those resources? Email, text, or other?
Are there any substance usage habits you are struggling with changing that you would like help with?
Fertility clients: Please tell us about diagnoses, menstrual cycle issues, and other fertility treatments
Anything else you'd like to inform us about: injuries, trauma, current pregnancy, or other health conditions ?
Notice
Thank you for filling out above intake form. There will be a one-page consent form to read and sign in person at your appointment. Just click that ‘submit’ button down below this. We are looking forward to meeting you soon in our clinic.
Email
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