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![Page 1: Cartersville Family Practice ACUPUNCTURE Medical ...Medical Acupuncture Patient Name_____ Date_____ Chief Complaint(s): Please indicate how long you have had the condition. Other Complaints:](https://reader034.vdocuments.net/reader034/viewer/2022042909/5f3c1a5556ea9615f264a25c/html5/thumbnails/1.jpg)
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
![Page 2: Cartersville Family Practice ACUPUNCTURE Medical ...Medical Acupuncture Patient Name_____ Date_____ Chief Complaint(s): Please indicate how long you have had the condition. Other Complaints:](https://reader034.vdocuments.net/reader034/viewer/2022042909/5f3c1a5556ea9615f264a25c/html5/thumbnails/2.jpg)
visit us online at harbinclinic.com/acupunture