New Patient FormACUPUNCTURE

visit us online at harbinclinic.com/acupunture

Cartersville Family Practice Medical Acupuncture

Patient Name_________________________ Date____________

Chief Complaint(s): Please indicate how long you have had the condition.

Other Complaints:

What kind of treatments have you received?

Reproductive & Gynecological (women only)

___# of pregnancies ___#of births __# of miscarriages ___length of periods Y/N irregular periods Y/N yeast infections Y/N painful periods Y/N PMS symptoms Y/N menopausalY/N painful ovulation Y/N heavy bleeding/clotting symptoms

visit us online at harbinclinic.com/acupunture