New Client Intake Form
Please fill in the form below.
Full Name
*
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
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Do you have any medical conditions?
*
No
High Blood Pressure
Diabetes
Arthritis
Osteoporosis
Lupus
Epilepsy/Seizure Disorder
HIV/AIDS
Herpes
Auto-Immune Disorder
Pace Maker
Cancer
Heart Condition
Hormonal Imbalance
Other
Are you taking any medications to help control any of the following conditions?
Blood Pressure
Diabetes
Pain
An active infection
Please list all RX Medications you are taking.
Please list any dietary / health supplements you are taking.
Do you have any known allergies?
Aspirin
Latex
Tree Nuts
Fruits
Vegetables
Dairy
Fragrance
Other
Please specify
What sort of reaction?
Have you had any surgeries or injuries in the past 6 months?
Yes
No
Please specify
Do you smoke?
Yes
No
Social
Do you drink 3 or more caffeinated beverages daily?
Yes
No
Are you pregnant or trying to become pregnant?
No
Yes
Currently breastfeeding
Given birth in the past year
N/A
If pregnant, how many weeks are you?
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received. I am aware that it is my responsibility to inform the practitioner of my current medical or health conditions and to update this history if anything changes. The treatments I receive here are voluntary and I release this institution and/or professional from liability and assume full responsibility thereof.
*
I have read and understand the conditions.
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