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New patient questionnaire - North Park Acupuncture

New patient questionnaire - North Park Acupuncture 2025

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The document is a comprehensive patient questionnaire for North Park Acupuncture, Inc., designed to collect essential personal, health history, and pain assessment information from new patients. It includes sections on personal details, medical history, family health issues, lifestyle habits, pain assessment, cancellation policies, and billing acknowledgments for treatments not covered by insurance.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your date of first visit at the top of the form. This helps establish your timeline with our clinic.
Fill in your personal information, including name, contact numbers, address, and email. Ensure accuracy for effective communication.
Provide details about your occupation, marital status, number of children, date of birth, age, height, weight, and hand dominance. This information is crucial for personalized care.
Indicate any previous experiences with acupuncture or chiropractic treatments and specify the reasons for those treatments.
List your primary health concerns clearly in the designated section to assist practitioners in understanding your needs.
Continue through the health history section by detailing any surgeries or allergies you may have. This ensures a comprehensive view of your health background.
Complete the pain assessment section by rating your pain levels and describing any discomfort areas. This will guide treatment planning.
Finally, review all sections for completeness before submitting. Your thoroughness aids in receiving optimal care.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (100 Votes)

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