Form----Acupuncture Pain Care in Greensboro, High Point, Kernersville, Winston-Salem, the piedmont at North Carolina (NC)

Please click here to open a printable version of the Patient Information Form. You can fill it out before your first visit.

Date:___ /___ /2013

Name:

Date of Birth:

Contact Phone:

Address
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Email address:
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Main Complaint:
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Any other problems you are concerned:
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Medical history related to your complaints:
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For Female: Are you a pregnant ? Yes No

Assessment and Plan:
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Acupuncture Pain Care is Chinese Medical Acupuncture in the piedmont at at NC (North Carolina). It include Greensboro,Kernersville,High Point and Winston-Salem at North Carolina (NC). The Office of Acupuncture Pain Care service for pain patients in Greensboro and Kernersville,High Point and Winston-Salem.
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