The Energy Remedy
New Patient Information Form
Name
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Contact Phone Number
Please enter a valid phone number.
Email
example@example.com
Referred by:
Occupation:
Employer:
Age:
Sex:
Height:
Weight:
Overall health:
Excellent
Good
Fair
Poor
Other
Chief complaint (reason you are here):
Previous treatments for this complaint:
Other complaints or problems:
Current medications/supplements/drugs being taken:
Are you currently under the care of a physician or other health care professionals? (If yes, please give name and date of last visit):
List any major illnesses (with approx. dates):
List any surgery or operations (with approx. dates)
Past accidents or injuries:
Marital Status:
Single
Married
Divorced
Widow
Name of Spouse:
Describe health of spouse:
Number of children if any:
Please list if there are any physical conditions or concerns with children for genetic purposes:
Any family history of serious illnesses:
Please Select
Cancer
Diabetes
Heart
Alzheimers
Other
Please elaborate on the above if any:
Any household pets or other animals you or family members are in close contact with:
What can we do to empower you to take control of your health?
On a scale of 1-10 (1 being least, 10 being most) how willing are you to change your lifestyle and supplement usage to resolve your symptoms?
Signature
Todays Date:
-
Month
-
Day
Year
Date
Submit
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