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Stephanie Pet ix Willard, L. Ac. 1033 SW Yam hill Street, Suite 100 Portland, OR 97205 503-227-8781 www.acupetix.com PERSONAL HISTORY QUESTIONNAIRE Today's Date: Name: Date of Birth: Age: Address:
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Gather all necessary personal information such as full name, date of birth, address, contact information, and social security number.
02
Provide details about any existing medical conditions, disabilities, allergies, or specific needs that Stephanie Petix Willard may have.
03
Fill out the insurance information section, including the name of the insurance provider, policy number, and any other relevant details.
04
Answer all questions accurately and honestly, providing detailed information about Stephanie Petix Willard's medical history, including previous diagnoses, treatments, surgeries, and medications.
05
If applicable, provide emergency contact information, including the names, relationships, and contact numbers of individuals who should be notified in case of an emergency.
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Submit the filled out intake form to the designated recipient or follow the specific instructions provided by the organization or healthcare provider.

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Stephanie Petix Willard intake is a form that collects information about an individual's intake process.
Stephanie Petix Willard intake must be filed by all individuals going through the intake process.
To fill out Stephanie Petix Willard intake, individuals must provide accurate information about their intake process and personal details.
The purpose of Stephanie Petix Willard intake is to gather essential information about an individual's intake process for record-keeping and assessment purposes.
Information such as personal details, medical history, intake process details, and any other relevant information must be reported on Stephanie Petix Willard intake form.
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