SHC Client Form

Date of Appointment

MonthDayYear
Full Name

First NameLast Name
Who were you referred by?
Email
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date

MonthDayYear
Height
Weight (lbs)
Age (Years)
Date of Birth

MonthDayYear
Marital Status
Do you have children
Occupation
Family Health History
Mother
Father
Brother
Sister
Your Health History
Check all that apply
What is Your History of Antibiotic Use?
Fasting Glucose
Testosterone (Men)
Vitamin D Level
Thyroid Reading
T3
T4
TSH
Food/Environmental Allergies or Sensitivities
What foods do you dislike?
Number of alcoholic drinks per week
Number of cups of coffee per day
Number of sodas per day
Number of glasses of water per day
Exercise pattern per week
Type(s) of Exercise
Stress level at work from 1-10 (10 is the highest)
Stress level at home from 1-10 (10 is the highest)
List any supplementation you take including brand name, type and amount.
Do you take any medication? If so, please list.
Do you have cancer?
If you have cancer, please give the specific type (i.e. ER positive breast cancer). If you are doing chemotherapy, please give the specific drug used.
Please describe in detail any significant health changes or surgeries you have had in the last 10 years.
What is your goal for the appointment today?
Should be Empty:

Family Health History