Health History Form

* This form is only to be filled out after you have paid a deposit to reserve a date for the Spero Clinic program.
Patient Deposit Agreement

I acknowledge that if I do not cancel my appointment outside of 4 calendar weeks of my appointment date, I forfeit my full deposit amount. I understand that this cancellation policy allows the Spero Clinic to give someone else the opportunity to make travel arrangements, so that they can rebook the appointment date.
Signature

Clear
Today’s date*

MonthDay Year
Date
Full Name*

First Name Last Name
Birth Date*

Month Day Year
Age*
Marital Status
Sex*
Social Security Number*
type n/a if not applicable
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number*

area code phone
Drivers License number*
Type n/a if not applicable
Email*
example@example.com
Emergency Contact Name*

First Name Last Name
Relation to Patient*
Type n/a if not applicable
Emergency Contact Phone Number*

area code phone
Your occupation *
Type n/a if not applicable
Your employer *
Type n/a if not applicable
How did you find out about our clinic?*

Areas Of Complaint
Using the pain drawing, Please mark the areas of the body where you have pain.
Please go into detail about the areas of pain you drew on the body diagram.*

0/100

Areas Of Complaint