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?
Do you exercise? What type?
Accidents/ Injuries
Surgeries/Hospitalizations
In case of Emergency, please contact: Name:
Phone:
Relationship to you:
ConstipationnoneCP
Back PainnoneCP
Fungal InfectionsnoneCP
Rheumatic FevernoneCP
AIDSnoneCP
DiarrheanoneCP
HypertensionnoneCP
BronchitisnoneCP
HypoglycemianoneCP
DepressionnoneCP
EmphysemanoneCP
MalarianoneCP
CancernoneCP
Heart DiseasenoneCP
IndigestionnoneCP
Mood SwingsnoneCP
PleurisynoneCP
MononucleosisnoneCP
StrokenoneCP
GastritisnoneCP
InsomnianoneCP
PneumonianoneCP
TuberculosisnoneCP
Pancreas ProblemsnoneCP
EpilepsynoneCP
FatiguenoneCP
Chicken PoxnoneCP
RheumatismnoneCP
Liver ProblemsnoneCP
DizzinessnoneCP
UlcersnoneCP
MeaslesnoneCP
ArthritisnoneCP
Kidney ProblemsnoneCP
MigrainesnoneCP
AllergiesnoneCP
German MeaslesnoneCP
DiabetesnoneCP
SyphilisnoneCP
HeadachesnoneCP
EczemanoneCP
MumpsnoneCP
Herpes Simplex noneCP
Herpes Simplex 1 noneCP
Earaches noneCP
Psoriasis noneCP
Whooping noneCP
Cough noneCP
Herpes Simplex II noneCP
Jaw Pain noneCP
Gonorrhea noneCP
Female Organ Problems noneCP
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