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Quick Query

Intake Form

Touch of Health Acupuncture & Wellness

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If you experiencing areas of discomfort please refer image and state below

Is your Discomfort:

Any Medical Diagnosis

How long have you had it?

Please choose the following option according to the degree of your discomfort:

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Are you currently taking any drugs, therapeutic or recreational?

Do you have any of the following symptoms?

Anything else that you think we should be aware of about your health condition?

FAMILY MEDICAL HISTORY (check appropriate boxes)

PAST MEDICAL HISTORY( check appropriate boxes)

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