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New Client Intake Form

Please complete this form to help us better understand your health history and prepare for your visit. All information provided is confidential and will only be used for your healthcare purposes.

Prescription Medications

(include those taken in the last month)

Herbs, Vitamins, Minerals, Food and Dietary Supplements

Drug or Food Allergies

Medical History

Cardiovascular/Circulatory System:

Digestive System:

Skin:

Musculoskeletal System: