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Youth Intake Form

Thank you for choosing ForeverYoung!

If you have booked an initial exam with us, please take the time to fill out this form the best you can prior to your appointment day. This helps to keep the clinic running smoothly and your appointment on time!

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HEALTH CARE PROVIDERS
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PATIENT SYMPTOMS
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How does their complaint interfere with the following areas of their life?

BIRTH HISTORY
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If vaginal with inteventions (check all that apply)
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CHEMICAL STRESSORS
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PSYCHOLOGICAL STRESSORS
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MEDICAL HISTORY
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QUALITY OF LIFE
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Thanks for submitting!