Confidential Client Case History and Intake Form
Dragonfly Transformation & Wellness
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referred by or How did you find us
Primary Concerns? Describe what you would like to accomplish with these treatments
*
Medications
Significant Accidents, Injuries, or Surgeries
Please place check any conditions that apply (past or present)
Cancer
Heart Disease
Pacemaker
Diabetes
Stroke
Epilepsy
Varicose Veins
H/L Blood Pressure
Paralysis
TMJ Dysfunction
Arthritis
Are you pregnant?
Other
Check any symptoms that you have recently experienced
Headache
Faintness/Dizziness
Tightness in Jaw
Weak body parts
Smoking
Anxiety/Nervousness
Increased or decreased Appetite
Excessive Urination
Grinding of Teeth
Heavy feeling in limbs
Blurriness of vision
Constipation or Diarrhea
Pains in heart/chest
Indigestion
Insomnia or Fatigue
Cold in hands and feet
Back or neck pain
Carpel tunnel syndrome
Menstrual Irregularities
Other
Save
Submit
Should be Empty: