New Client Questionnaire

This is a confidential questionnaire to help determine the best treatment plan, please fill out as completely as possible, you may leave sections blank if so desired. Thank you!

First & Last Name

Date of Birth

Gender

M

F

N/A

Mailing Address

Phone Number

Email Address

Emergency Contact

Emergency Contact Phone

Are you currently under the care of another healthcare provider?

For what condition?

Concurrent Healthcare Provider

Are you currently taking any prescription or over the counter (OTC) medications?

Are you currently taking any nutritional supplements (vitamins, minerals, herbs, powders, tinctures)?

Please indicate all that apply:

PREGNANCY

HIGH BLOOD PRESSURE

BLOOD THINNERS

ANEMIA

HIV

HEPATITIS

SEIZURES

PACEMAKER

Any surgically implanted bone/joint replacement/stabilizer? Where?

Surgical removal of significant organs/tissue? Where?

How did you hear about us?

Today's Date

I declare that the info I’ve provided is accurate & complete

I accept terms & conditions

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