Healing Tree New Client Information Form

Healing Tree Natural Health

New Client INFORMATION FORM
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone
Please enter a valid phone number.
Email
example@example.com
REFERRED BY Type here
Occupation Type here EmployerType a label
Date of Birth MM/DD/YYYY Age Type Here HeightType Here
WeightType Here
Sex

MaleFemaleN/A
Overall health

ExcellentGoodFairPoorOther
Chief complaint (reason you are here)
Previous treatments for this complaint
Other complaints or problems
Current medications/drugs being taken
Are you under the care of a physician or other health care professionals?

YesNo
Name Type Here Date of last visit DD/MM/YYYY
Nutritional supplements you are taking
Do you smoke cigarettes?

YesNo
If YES, how many cigarettes per day?
Do you drink coffee?

YesNo
If YES, how many cups per day?
Do you drink alcohol?

YesNo
If YES, how many drinks per day?
List any MAJOR ILLNESSES with APPROXIMATE DATES
List any SURGERY or OPERATION with APPROXIMATE DATE
List any past ACCIDENTS or INJURIES
Any family history of serious illnesses such as

CancerDiabetesHeartOther
Any household pets or other animals you or family members are in close contact with
Marital status

SingleMarriedDivorcedWidowed
Name of spouse

First NameLast Name
Number of children (if any) Type Here
NAME(s) of child (or children), SEX, and AGE Name, Sex, Age
Any physical conditions or concerns? Type Here
What can we do to make you HAPPIER?
Should be Empty:

Healing Tree Natural Health