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New Patient Form ACUPUNCTURE visit us online at harbinclinic.com/acupunture 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 menopausal Y/N painful ovulation Y/N heavy bleeding/clotting symptoms
