Skip to content
Toggle Navigation
Home
Program
Apply – Free Clarity Call
Blog
About
Contact
Login
Cart
0
New Client Intake Form
admin
2020-04-01T04:52:54-08:00
Name
Date of Birth
Address
City, State, Zip
Phone (Hm)
Wk
Cell
Email
Occupation
Employer
Relationship Status
Children/ages?
Referred By
Reason for Today's Visit
What are your goals/ expectations from this healing today? Long range?
What do you see as recurring issues (physical, emotional) in your life?
Have you had experience with complementary/ alternative therapies?If so,What are they?
Physician (name, phone)
Antibiotics/ Medications Currently Taken
Non-Prescription Drugs/Supplements Currently Taken
General Type of Diet
Alcohol Intake?
Tobacco/ Cigarettes?
General Type of Diet
Do you exercise? What type?
Accidents/ Injuries
Surgeries/Hospitalizations
In case of Emergency, please contact: Name:
Phone:
Relationship to you:
Do you have or have you had: (Please mark "C" to indicate current symptoms or "P" for symptoms you have had in the past.)
Constipation
none
C
P
Back Pain
none
C
P
Fungal Infections
none
C
P
Rheumatic Fever
none
C
P
AIDS
none
C
P
Diarrhea
none
C
P
Hypertension
none
C
P
Bronchitis
none
C
P
Bronchitis
none
C
P
Hypoglycemia
none
C
P
Depression
none
C
P
Emphysema
none
C
P
Malaria
none
C
P
Cancer
none
C
P
Heart Disease
none
C
P
Indigestion
none
C
P
Mood Swings
none
C
P
Pleurisy
none
C
P
Mononucleosis
none
C
P
Stroke
none
C
P
Gastritis
none
C
P
Insomnia
none
C
P
Pneumonia
none
C
P
Tuberculosis
none
C
P
Pancreas Problems
none
C
P
Epilepsy
none
C
P
Fatigue
none
C
P
Chicken Pox
none
C
P
Rheumatism
none
C
P
Liver Problems
none
C
P
Dizziness
none
C
P
Ulcers
none
C
P
Measles
none
C
P
Arthritis
none
C
P
Kidney Problems
none
C
P
Migraines
none
C
P
Allergies
none
C
P
German Measles
none
C
P
Diabetes
none
C
P
Syphilis
none
C
P
Headaches
none
C
P
Eczema
none
C
P
Mumps
none
C
P
Herpes Simplex
none
C
P
Herpes Simplex 1
none
C
P
Earaches
none
C
P
Psoriasis
none
C
P
Whooping
none
C
P
Cough
none
C
P
Herpes Simplex II
none
C
P
Jaw Pain
none
C
P
Gonorrhea
none
C
P
Female Organ Problems
none
C
P
Click here to download application form
Upload Form
×
Close product quick view
×
Title
Page load link
Go to Top
