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Client Intake Form
Full Name
Email
Date of Birth
Phone number
Symptoms
Health History
Chronic Conditions
Hypertension
Diabetes
High Cholesterol
Heart Disease
Asthma
Osteoarthritis
Rheumatoid Arthritis
Cancer
Stroke History
Thyroid Disorders
Epilepsy
Depression / Anxiety
No Chronic Conditions
Medications
First Visit Date
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