Northern Appalachia Clinic New Client Form
This form has been designed to help me get to know you better, so that we can make the best of our scheduled appointment time together and guide you effectively. I ask that you please complete it to the best of your ability. If there are sections that you feel uncomfortable writing about, and would rather discuss in person, either for ease of mind or out of practicality, I am happy to accommodate you. I invite you to make notes on your form and ask questions upon arrival to your appointment. For your safety, I do request transparency with diagnosed medical conditions and allergic reactions, as well as that medications, herbs, and supplements you are currently taking. Thank you!
General Info
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Full Name
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First Name
Last Name
Preferred Name/Nickname
Today's Date
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Month
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Day
Year
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E-mail
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Cell phone #
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Area Code
Phone Number
Alternate phone #
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Area Code
Phone Number
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Cell phone
Home phone
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Address
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Street Address
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City
State / Province
Postal / Zip Code
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Canada
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China
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Cuba
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Cyprus
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Democratic Republic of the Congo
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Djibouti
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Estonia
Ethiopia
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Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Ghana
Gibraltar
Greece
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Guinea
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Hong Kong
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India
Indonesia
Iran
Iraq
Ireland
Israel
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Kenya
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North Korea
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
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Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
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Togo
Tokelau
Tonga
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Trinidad and Tobago
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Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
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Ukraine
United Arab Emirates
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United States
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Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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Emergency Contact Name
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Emergency Contact Phone #
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Area Code
Phone Number
Emergency Contact Relationship
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Medical History
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Birth date:
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Month
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Day
Year
Date
Height
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Weight
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Sex/Gender
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Please note if sex assigned at birth differs from gender identity
Pronouns
How would you rate your current overall health?
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2
3
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5
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7
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9
10
Worst
Best
1 is Worst, 10 is Best
Primary Health Complaint and/or Goal
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How would you rate this health complaint (if applicable)?
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2
3
4
5
6
7
8
9
10
Minimally impacts daily life
Severely impacts daily life
1 is Minimally impacts daily life, 10 is Severely impacts daily life
Secondary complaints and/or health goals (if applicable)
Last physical exam?
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Month
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Day
Year
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Last gynecological exam (if applicable)?
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Month
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Day
Year
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Are you currently under the care of a physician?
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Yes
No
Physician's Name
First Name
Last Name
Physician's Phone #
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Area Code
Phone Number
Are you currently seeing any medical specialists or other practitioners related to your health? If so, please provide their name(s) and specialty.
Current medical diagnoses
List history of previous injuries, surgeries, or hospitalizations and date(s)
Known Allergies (if none known, list "none")
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Have you taken antibiotics in the past five (5) years?
Please Select
Once
Twice
Multiple
Currently on antibiotics
Do you take NSAIDS (ibuprofen/Motrin, naproxen/Aleve, etc.)?
Yes, daily
Yes, frequently
Yes, occasionally
No, never
If yes, last date antibiotics taken:
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Month
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Day
Year
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Medications (prescription and nonprescription), please list name, dosage, # per day, and start/end dates
Supplements/Herbs/Vitamins/Minerals (please list form, brand, dosage, # per day)
Other current/recent complimentary therapies (massage, acupuncture, etc.)
What is your ethnicity/ancestry?
Family Health History
Allergies
Arthritis
Auto-immune Disease
Cancer
Diabetes
Eczema
Heart Disease
Hypertension
Mental Illness
Osteoporosis
Thyroid Disease
Other
Personal Health History (please check all that apply)
Acne
Allergies
Anemia
Anxiety Disorder
Arrythmia
Arthritis
Asthma
Bronchitis/Emphysema
Cancer
Celiac
CIRS (Chronic Inflammatory Response Syndrome)
Concussion/Head trauma
Depression
Diabetes
Dizziness or fainting
Eczema
Eplilepsy/Seizure disorder
Fatigue
Gastrointestnial Disorder
Genitourinary Disorder
Gout
Heart Disease
Heart Murmur
Hypertension
Kidney Disease
Lyme Disease
Lyme Co-Infection/Other Tick-Borne Disease
Menstrual Dysfunction
Mental Illness
Osteoporosis
STD
Shortness of Breath
Stroke
Thyroid Disease
Tuberculosis
Other
Other notable health conditions or experiences
Do you experience any of the following? (Check all that apply)
Bloating
Indigestion
Heartburn/Reflux
Consitpation
Diarrhea
Gas
Stomach Cramps
Are you sexually active?
Yes
No
Date of Last Menstrual Cycle (if applicable)
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Month
-
Day
Year
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Lifestyle
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Marital Status
Single
Married
In a relationship
Divorced
Widowed
Do you have children?
Yes
No
Occupation
Briefly describe your living situation:
Are you aware of any notable environmental toxin exposure at work, at home, or in your daily life?
Please rate your current stress level:
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2
3
4
5
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9
10
Stress-free
Very Stressed
1 is Stress-free, 10 is Very Stressed
How many hours of physical activity do you get each week, and what kind?
How many hours of sleep do you get on weeknights?
Weekends?
Do you feel rested upon awakening?
Yes
No
Sometimes
Do you currently follow a special diet or dietary restriction?
Religion or Spiritual beliefs?
Hobbies
Other comments:
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