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Marlborough Wellness Center, Marlborough, MA

Acupuncture, Massage and other modalities in Marlborough MA

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Women’s Health History and Intake Form

Women's Health History and Intake Form

  • Your Medical Contacts

  • All About You

    Check all that apply.
  • Your Past Medical History

    Next to each illness/condition that you have experienced, enter details and specific dates
  • Personal Information

  • Average Daily Diet - Please describe in detail

  • In all the areas listed below, please check if you have experienced any symptoms in the past 3 months

  • Gynecological History

  • Please list and enter date(s)
  • Menstruation

  • Presence of Clots

  • Vaginal Discharges

    Check all that apply
  • Pain During Menses

    Check all that apply.
    Check all that apply.
    Check all that apply.
  • Clinical Manifestations

    Check all that apply.
  • Reproductive

  • Oral Contraception/Birth Control Pill

  • Musculoskeletal

  • Neuropsychological

  • This field is for validation purposes and should be left unchanged.

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