PRELIMINARY HEALTH INTAKE FORM
If you are contemplating becoming a client, it would be necessary for you to fill this form out, print it and either mail me a hard copy or e-mail it. By filling out and sending the below information, you are not committing to anything nor am I; however, it is necessary for me to have certain information about you and your situation so that I can determine whether or not I could be of assistance to you.
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PRELIMINARY HEALTH INTAKE FORM DATE_______________________ NAME______________________________________ ADDRESS__________________________________________________________________________________City______________________________ State _________ Zip code _____________ PHONE NUMBER(S)__________________________________________________ E-MAIL___________________________________________________________ HEIGHT_______ WEIGHT________ AGE____BLOOD PRESSURE___________ PULSE______ TEMPERATURE_____ WHAT IS/ARE YOUR MAJOR COMPLAINTS? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ FAMILY HISTORY? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ WHAT DO YOU THINK ARE THE CAUSES OF YOUR HEALTH PROBLEMS? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ HOW LONG HAVE YOU HAD THIS/THESE CONDITIONS? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ WHAT TREATMENTS, INCLUDING DRUGS ARE YOU PRESENTLY UNDERGOING OR HAVE HAD IN THE PAST? (Please specify if present or past) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ RESULTS OF THESE TREATMENTS/SUBSTANCES? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ SURGERIES? (And dates) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ |
