Intake Form

Name*

First NameLast Name

Date of Birth*

DayMonthYear

Occupation*

How did you hear about me?

Address:*

Street Address

Street Address Line 2

CityCounty/State/Province

Postal / Zip CodeCountry

Email

example@example.com

Can we contact you over email?

Preferred Phone Number*

Country CodePhone Number

What exactly are you looking for help with? What results are you looking to receive? (A brief summary of important things that you are currently experiencing & what you would like to see shift or improve as a result of Johnny's work.)*

If you have a current health condition, or have been diagnosed with one in the past, (eg. heart disease, diabetes, cancer, etc...)

Please list here in as much detail as possible making a distinction between what you are currently experiencing and what may be important to know from your past health history. How long have you been struggling with the issue(s)?

Medical Condition(s):

Date

Date of diagnosis

Treatment Received

YesNo

Any history of surgery or hospitalisations?

YesNo

List Here (Date, Frequency, Treatment provided)

Please list all Surgery/Hospitalisation and Dates

Please indicate if you are CURRENTLY experiencing any of the following,

Muskuloskeletal

Joint PainMuscle PainStiff Joints

Nose and Sinus

Sinus InfectionsSinus PainRunny Nose

Skin

Cardiovascular System

Mouth and Throat

Neurological

Respiratory

Endocrine System

Mental/Emotional Health

Urinary System

Digestive System

Immune System

Frequent Colds/FlusCancerAllergiesAuto-immune Disease

Have you received any vaccinations in the last 5 years? (Please list)*

Are you currently pregnant?*

YesNoPossibly

Are you trying to become pregnant?*

YesNo

Please list anything else, or elaborate on the above if you would like.

**To share Medical Images, Blood Tests & Other Documents that you believe will be helpful for Johnny while reviewing your case, please send directly to our e-mail themedicalhealer@gmail.com **

New Client Intake Form

Contact Information

Health Information and History

Health Assessment and Medical Information

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