Health Evaluation Form

1

Full Name

First Name

Last Name

2

E-mail

3

Phone Number

Area Code

Phone Number

4

Name of Doctors practice or other health professionals you are currently seeing

5

Date of Birth

6

Do you have known allergies?* This field is required.

7

Please list any known allergies* This field is required.

8

Please list any medications you are currently taking (e.g. warfarin, contraceptives, laxatives)

9

Please list any supplements you are currently taking

10

Do you have a main health complaint? Please describe.

12

Additional info you might want to share

13

Agree and consent.I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that withholding information may affect the treatment results and safety. I agree to proceed with the treatment discussed.Client Signature:

14

Date