The Nest
Blythe Ross LMT
Blythe Body LLC
1717 S. Cheyenne Ave
Tulsa, OK 74119
(918) 261-4149
ADULT INTAKE FORM
Name:
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Today's Date:
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DOB:
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Month
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Sex:
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F
Number of Children:
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Phone:
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Format: (000) 000-0000.
Address:
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Email:
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example@example.com
Reason for Being Seen:
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How long has this issue been presenting?
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Surgeries:
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Accidents:
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Medications / Supplements:
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Increments of sleeping time?
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Bowel Movements / how often / consistency?
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Name of Doctor / Chiropractor / Functional Medicine Doctor:
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Labor and Delivery / How long? / Hospital or home? / Drugs? / c-section or natural birth?
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What other modalities have you tried to help with these issues?
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Additional Information:
(Print Name), agree to let Blythe Ross LMT treat me. I agree not to hold Blythe Ross LMT or Blythe Body LLC liable for any health problems that may occur after this visit.
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Patient Signature:
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Date:
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Month
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Day
Year
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