Client History

Bring the form with you on your first office visit or print to forward by email in advance of your first Telephone Appointment. Thank you in advance for your attention to this detail.

 

NAME____________________________________________________ DATE___________________________________

ADDRESS__________________________________________________________________________________________

CITY _______________________________ STATE ________________ ZIP _____________

HOME PHONE ______________________ WORK __________________ CELL____________________

AGE_____ DATE OF BIRTH_____________ BIRTHPLACE__________________________

SOCIAL SECURITY NUMBER (Responsible Party) ________-________-________

OCCUPATION ______________________________________________________________________________________

EMPLOYER’S NAME AND ADDRESS: _____________________________________________________________________

REFERRED BY ______________________________________________________________________________________

PERSON TO CONTACT IN CASE OF EMERGENCY:

NAME ___________________________________ HOME PHONE ___________________________

WORK PHONE _____________________________

LIST HEALTH PROBLEMS/COMPLAINTS IN ORDER OF IMPORTANCE.


1)
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_________________________________________________________________________________________________________________________

2)
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3)
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ARE ANY CONDITIONS DUE TO INJURY OR SICKNESS ARISING OUT OF YOUR EMPLOYMENT ___________


HAVE YOU HAD THE SAME OR SIMILAR SYMPTOMS BEFORE? _________ IF SO, WHEN? ______________


HAVE YOU SEEN A PHYSICIAN FOR THE ABOVE CONDITIONS? _________ IF SO, WHO AND WHEN?


DATE OF YOUR LAST COMPLETE PHYSICAL EXAM ______________________________________________


MEDICAL HISTORY:


CURRENT MEDICATIONS:


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NUTRITIONAL SUPPLEMENTS, HERBS:


_________________________________________________________________________________________________________________________



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ADDITIONAL COMMENTS:


_________________________________________________________________________________________________________________________



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OTHER HEALTH CONCERNS:

_________________________________________________________________________________________________________________________



_________________________________________________________________________________________________________________________



MAJOR ACCIDENTS:


_________________________________________________________________________________________________________________________



_________________________________________________________________________________________________________________________



ADDITIONAL COMMENTS:


_________________________________________________________________________________________________________________________



_________________________________________________________________________________________________________________________

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FREE 30 min CONSULT ($60 Value) with purchase of SECRETOR STATUS Test ($35 Value) within 15 days of first consult or first purchase.

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