©2019 by Life Healing Center PC.

NEW PATIENT INTAKE 

PATIENT INFORMATION

Gender
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Appointment Reminders:

SOCIAL HISTORY

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Employment Status
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CURRENT BEHAVIORAL HEALTH STATUS

Are you experiencing any of the following?

FAMILY HISTORY

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MEDICAL HISTORY

Do you have/had any of the conditions listed below:

MEDICATIONS/PHARMACY INFO

ALLERGIES

OTHER HEALTH INFO

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