Intake Paperwork
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First & Last Name
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Email
Address
How did you hear about us?
Do you have Medicaid, Medicare or Soonercare?
Medicaid
Medicare
Soonercare
Does not apply to me
Are you a Veteran?
Yes
No
Do you take any medication?
Yes
No
Medical History - Select any that apply
Glaucoma
Parkinson's Disease
Huntington's Disease
Multiple Sclerosis
ALS
HIV/AIDS
Chrohn's Disease
Ulcerative Colitis
IBS
Ulcers
Cancer
Asthma
Diabetes
Neuropathy
Kidney Disease
Psoriasis
Psoriatic Arthritis
Seizers
COPD
Congestive Heart Failure
Stroke
Medical History - Continued
Osteoarthritis
Lupus
Paralysis
PTSD
Anxiety
Depression
Insomnia
Headaches
Migraines
Nausea
Poor Appetite
Chronic Pain
Chronic Back Pain
Chronic Neck Pain
Sciatica
Numbness or Tingling
Hyperlipidemia
Hypothyroidism
Skin Issues
Obesity
Other Condition
State Form of I.D. (FRONT)
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Other Conditions NOT listed
Important Medical Family History
Any major surgeries?
Signature
State Form of I.D. (BACK)
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Birthday
Phone