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CHILLIWACK MOUNTAIN MEDICAL TODAYS DATE / / MMDDADULT INTAKE FORM BIRTHDATE / / YYYYMMDDAGE: YYYYFULL NAME PREFERRED NAME GENDER PREFERRED PRONOUNS MARITAL STATUS CARE CARD # ADDRESS CITY POSTAL CODE
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Start by reading the instructions carefully.
02
Gather all necessary information such as personal details, medical history, and current medications.
03
Begin filling out the form by providing your full name, date of birth, and contact information.
04
Proceed to answer questions regarding your medical history, including any previous surgeries or hospitalizations.
05
Indicate any current medical conditions or chronic illnesses you may have.
06
Provide details about any allergies or adverse reactions to medications.
07
List all medications you are currently taking, including over-the-counter drugs and supplements.
08
If applicable, mention any mental health conditions or history of psychological treatment.
09
Answer questions about your lifestyle habits such as smoking, alcohol consumption, and exercise routines.
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Review the completed form to ensure all information is accurate and legible.
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Sign and date the intake form as required.
12
Submit the filled-out form to Copacetic Bodyworks for their records.

Who needs copacetic bodyworks medical intake?

01
Anyone who seeks treatment or services from Copacetic Bodyworks is required to fill out the medical intake form.
02
This includes both new and returning clients.
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The form helps the practitioners at Copacetic Bodyworks to gather essential health information and provide appropriate care.
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Filling out the medical intake form is a standard procedure for ensuring the well-being and safety of the clients.
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Copacetic bodyworks medical intake is a process used by health care providers to gather essential information from patients before treatment.
All patients seeking treatment at Copacetic Bodyworks are required to complete the medical intake form.
To fill out the copacetic bodyworks medical intake, patients should provide personal information, medical history, and any current medications they are taking.
The purpose of the copacetic bodyworks medical intake is to collect important health information that helps providers understand patient needs and tailor their care.
Information required includes the patient's name, contact details, health history, allergies, and a list of medications.
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