CLIENT HEALTH QUESTIONNAIRE
PRIOR TO THE START OF MY SERVICE, I CONFIRM THAT:
Does the patient have a fear of needles?
Yes
No
Has the patient had a mastectomy, If so on which side ?
Yes
No
In the past did patient ever faint during a blood draw ?
Yes
No
Signature:
Patients Name:
Patients Date of Birth:
Phone Number:
Address:
Emergency Contact Name:
Emergency Contact Number:
Upload your ID:
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Upload your Insurance card:
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Date:
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