Client intake form

CLIENT INTAKE FORM

It is mandatory to fill out all fields prior to your appointment
GENERAL INFORMATION
DayMonthYear
2 digit day, 2 digit month, 4 digit yearTodays Date
How did you hear about us?
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age
Gender
Contact Preference
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name
Contact Number
Format: (000) 000-0000.
Relationship
WHAT ARE YOUR GOALS WITH DMD FUSION? List 3
(Weight Loss, Skin/body Rejuvenation, overall health, general health maintenance)
GENERAL HEALTH QUESTIONAIRE
Family GP Name
Contact Number
Format: (000) 000-0000.
Do you have any health problems and/or concerns?
Please give a brief explanation here:
Do you have any allergies or sensitivities?
Please give a brief explanation here:
Do you Smoke?
How many cigarettes per day?
Do you vape?
Estimated time spent vaping:
Do you consume alcohol?
Alcohol preference:
How often do you exercise?
Do you take vitamins/ supplements?
If yes, what type/s?
Daily water intake:
ENVIRONMENTAL/ DETOXIFICATION HISTORY
Do any of these significantly affect you?
If other, please specify:
Do any of these significantly affect you?
Do you have a history of a significant exposure to any harmful chemicals?
If yes, please give a brief explanation, chemical name & date of last exposure:
NUTRICIAN & PREFERENCES
Nutritional preferences would include; (Tick all that apply)
SYMPTOM REVIEW ( Physiology and Function)
Below is a list of conditions, which may seem unrelated to the purpose of your appointment however, these questions must be answered carefully as these problems can affect your overall diagnosis and treatment plan. Please indicate symptoms that occur presently or in the last 6 months by indicating their severity.
1 = Never 2 = Mild 3 = Moderate 4 = Severe

GENERAL

Rows	NUMBER RATING
Cold hands & Feet
Daytime sleepiness
Difficulty falling asleep
Fatigue
Night Sweats
Hot Flushes
Sleeplessness

HEAD, EYES & EARS

Rows	NUMBER RATING
Ear Ringing/buzzing
Headaches
Migraine
Hearing Problems
Sensitivity to Light
Sensitivity To Noise
Vision Problems

MUSCULOSKELETAL

Rows	NUMBER RATING
Back Muscle Spasm
Calf Cramps
Chest Tightness
Foot cramps
Joint Pain
Joint Stifness
Muscle pain
Muscle Spasms
Muscle stiffness
Muscle Twitches
Muscle Twitches around eyes
Muscle Twitches in arms or legs
Muscle Weakness
Neck muscle pain

RESPIRATORY

Rows	NUMBER RATING
Bad breath
Bad odor in nose
Hay Fever: Spring
Hay Fever: Summer
Hay Fever: Winter
Hay Fever: Autumn
Hay Fever: Every change of Season

EATING

Rows	NUMBER RATING
Can’t gain weight
Can’t lose weight
Carb Intolerance
Poor appetite
Frequent dieting
Diabetic

ITCHING SKIN
If yes please explain

MOOD/NERVES

Rows	NUMBER RATING
Anxiety
Depression
Difficulty Concentrating
Difficulty with Balance
Difficulty with Speech
Difficulty with Memory
Dizziness
Fainting
Irritability
Light- Headedness
Numbness
Panic attacks
Seizures

CARDIOVASCULAR

Rows	NUMBER RATING
Angina/ chest pain
Breathlessness
Heart Attack
Heart Murmur
High Blood pressure
Low Blood Pressure
Irregular Pulse
Palpitations
Swollen Ankles/feet
Varicose Veins

URINARY

Rows	NUMBER RATING
Infections
Kidney Disease
Kidney stone
Prostate Problems

DIGESTION

Rows	NUMBER RATING
Bleeding Gums
Bloating in Abdomen
Blood in Stools
Constipation
Cracking at Lip corners
Cold Sores
Diarrhoea
Dry Mouth
Flatulence
Reflux
Heartburn
Liver Disease/ Jaundice
Nausea
Sore tongue
Vomiting

COSMETIC SURGERY

Rows	NUMBER RATING
Breast Augmentation
Nose
Botox
Fillers
Threads
Tooth implants
Any body implants
Pace maker
Stents
Sports injury
Vasectomy
Hysterectomy
Birth Control Implants

Anything not on this list; (please give brief explanation and date)
ACKNOWLEDGEMENTS AND CONSENT
To set clear explanations, improve communications, and help you get the best results please read each statement and initial your agreement.

CANCER

Rows	INITIAL
I instruct the therapist and/or health care practitioner to deliver the care that, in his or her professional judgement, can best help me in the restoration of my health. I also understand that the treatments offered in this practice are based on the information provided by myself to the best of my knowledge and that any omissions can impair my results.
I agree to follow the instructions for pre-care and after care as provided and accept that failure to do so may impair my results.
I have read the Privacy Policy provided on the website and agree to the terms. I understand how my personal health information is protected and used only by DMD Fusion to provide me with the most suitable treatments.
I grant permission to be called to confirm or reschedule an appointment and to be sent occasional promotional messages, emails and/or whatsapp messages containing health information to me as an extension of my care at DMD Fusion.
I understand that I am fully responsible for the payments of my treatments at DMD Fusion.
To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern. I represent and warrant that I am at Least 18 years of age and may legally agree to this agreement. DMD Fusion assumes no responsibility or liability for any misrepresentation of your age.
The service provider being DMD Fusion (Pty) Ltd is hereby indemnified by ____(full name)_________ Against all actions, claims, losses and possible expenses in respect of any loss or damage to itself or to any third party that may arise from the services as provided by the service provider to and in favour of said client.

Patient Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty:

CLIENT INTAKE FORM

GENERAL INFORMATION

GENERAL HEALTH QUESTIONAIRE

ENVIRONMENTAL/ DETOXIFICATION HISTORY

NUTRICIAN & PREFERENCES

SYMPTOM REVIEW ( Physiology and Function)

ACKNOWLEDGEMENTS AND CONSENT