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Step 1 of 2 – Medical History

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ACUPUNCTURE

Patient Intake and Medical History
Today's Date*
Legal Full Name of Patient*
Preferred Name
Date of Birth*
Note: For patients using insurance, this field must match what is on file with your insurance company
Address*
Consent to leave a voicemail?*
SMS Consent*
See SMS Terms & Conditions I can change my decision for consent at any time by providing consent in writing to contactus@hhamd.com.
Language*

Have you had Acupuncture before?*
Have you taken Chinese Herbal Supplements?*
We want to do everything we can to make you comfortable. Do you require additional accomodations?*
Are you currently pregnant?*
Do you have issues climbing stairs? (we have upper level treatment rooms)*
Is the reason you are coming related to a Workers Comp, Auto Accident or Personal Injury case?*
Our office does not process to your personal health insurance for Workers Comp, Auto Accident or Personal Injury related cases unless you provide a Letter of Subrogation from your insurance company or a PIP exhaust letter to our office. If you are unable to provide that to our office, you will be required to pay the self-pay rate at each appointment and we will not process your claim to your insurance. We can give you the appropriate supporting documents to seek reimbursement on your own. If you have any questions or would like to speak to someone further, please call our main number at 301-620-1414 and leave a voicemail with our Insurance Team or email insurance@hhamd.com.
Do you have an insurance plan that offers acupuncture coverage?*
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Medical/Family History

Please select if you or your immediate family member has history with these conditions.
Are you currently undergoing cancer treatment?*
Do you have a regular Exercise Program?*
Do you smoke cigarettes?*
If yes, how many per day?
How much coffee, tea or caffeine per week?*
How much alcohol per week?*

Current State of Health – Check All That Apply

Please mark the checkbox if you have experienced any of these conditions in the past 4 weeks.
Constitutional/General
Eyes
ENMT
Cardiovascular
Respiratory
Gastrointestinal
Uro-Genital
Skin
Musculoskeletal
Neuropathy/Psychology
Gynecology (Women)
Do you use birth control?*
This field is for validation purposes and should be left unchanged.

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