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    • New Patient Intake Form

    • Welcome to the Jade and Cinnabar Oriental Medicine Center. Please take the time to fill out the questionnaire as carefully and thoroughly to facilitate a complete evaluation. All information is strictly confidential.

    • New Patient Intake Form
      First
      Last

      Contact Information

      Address
      Address 1
      Address 2
      City
      State
      Zip
      Cell
      Home
      Work

      Patient Information

      lbs
      Feet
      Inches
      If under 18
      Relationship to Patient
      First Name
      Last Name
      Phone
      Relationship to Patient

      Primary Physician Information

      First Name
      Last Name
      Primary Physician Address
      Address 1
      Address 2
      City
      State/Province
      Zip/Postal
      Phone Number
      Condition(s) your physician is currently treating you for

      Medical History Information

      Illness, hospitalization, surgery or accidents. Please list in chronological order and indicate length of injury or trauma.
      Age
      Event
      Outcome

      All Medications

      Please list all medications including prescriptions, vitamins, herbs, and supplements taken within the last six months, dosage and frequency with which you take them, and the condition or symptoms you take them for.
      Medication
      Dose / Frequency
      Condition/Symptoms

      Health Concerns Information

      Please list complaints in order of importance to you.
      Complaint
      To what extent does this problem affect your daily activities (work, sleep, eating, etc.)?
      How long has it been since you first noticed any symptoms?
      Have you been given a diagnosis by a physician or chiropractor? If so, what is it?
      What kinds of treatment or therapy have you tried?
      Is the condition getting better?
      Do you have an opinion or insight on what might have caused your complaint?

      Lifestyle Information

      What is your definition of health?
      What are your health goals?