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NEW PATIENT INTAKE FORM

Personal Information

Tell us about yourself

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Occupation

In case of an emergency who should we contact?

Medical Information

What are your main complaints? (Please check all that apply)
Which statements best describe why you are here today? (Please check all that apply)
Would you rate your diet as:
Are you currently pregnant or breastfeeding?
Have you ever been told that you have an electrolyte imbalance or other abnormal labs? (Please check all that apply)
Are you a diabetic
Are you a smoker?
Do you use any recreational drugs?
Do you have any medication or food allergies?
Do you have any of the following conditions? (Please check all that apply)

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