New Client Intake Form

Date

First name

Last name

Address

Phone

Email

Date of Birth

Age

Occupation

What are your main complaints?

Have you had laboratory testing or blood within the last year?

Yes

No

Anything of concern from recent lab or blood test?

Do you have any of the following?

Allergies to drugs, foods, chemicals, supplements, sulphites? If YES, please specify.

Please check here if you attest to none of the above.

NONE OF THE ABOVE

List any other conditions not listed above

Are you a diabetic?

Yes

No

If YES, is your diabetes under control?

Yes

No

Are you a smoker? If YES, how much do you smoke per day?

How many alcoholic drinks do you consume in a week?

Do you use any recreational drugs? If YES, which ones and how often?

Have you ever fainted? If YES, please give details

Check any of the following that you are currently taking:

Over the counter drugs? Name, strength, frequency, condition being treated

Vitamins and other supplements? Name, strength, frequency, condition being treated?

Is there anything else you would like us to be aware of about you or your health concerns?

By checking is box I affirm that I have answered the above questions and statements truthfully and to the best of my knowledge