Therapeutic New Client Information

Therapeutic New Client Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referred By:
Occupation
Employer
Date of Birth

MonthDayYear
Date
Age
Sex
Height
Weight
Emergency Contact
Emergency Contact Phone

Area CodePhone Number
Marital Status
Name of Spouse
Describe Health of Spouse
Number of Children
Please list your children(s) names, age, sex and any physical conditions or concerns you may have.
Family History of (select all that apply)

CancerDiabetesHeart DiseaseOther
Please mark all conditions that apply to your personal health history.

Heart DiseaseHigh Blood PressureLow Blood PressureVaricose VeinsBlood ClottingCirculatory DisordersStrokeSkin ConditionsAllergiesCancerEpilepsySeizuresMultiple SclerorisOsteopeniaOsteoporosisScoliosisMigraine HeadachesTMJ DysfunctionNeck PainShoulder PainMild/Low Back PainSciaticaHip & Knee PainBulging DiscThyroid DiseaseDiabetesHypoglycemiaCarpal Tunnel SyndromeThoracic Outlet SymdromeFever (last 24hrs)Communicable DiseaseHIV VirusOther
Please list any hospitalization date(s) and conditions you were hospitalized for.
Please list any injuries incurred and date(s) you suffered injury.
How would you rate your overall health?
Chief complaint (reason you are here)
Previous treatment (if any) for this complaint
Any other complaints/problems?
Please list your current medications/drugs being taken.
Major illnesses
Major surgery/operations (with approx. dates)
Accidents or Injuries
If you are currently under the care of a physician, please list physician name and date of last appointment.
Supplements you are taking
Allergies
Do you?

Use CigarettesDrink CoffeeDrink AlcoholType option 4
Do you have indoor pets?
If yes, please list all pets here.
Any other information you would like us to be aware of?
Appointment Reminders
OFFICE POLICIES:

Payment Policy: I understand that all services are rendered on a cash, check, or credit card basis. Unless other arrangements have been made in advance, I agree to pay for each session at the time of the session. I also agree to the $20 return check charge in the event that my check is returned.

Cancellation Policy: I understand that any appointment NOT cancelled more than 24 hours prior to the scheduled time will be billed $40. There will be one “grace” given for a missed or late-cancelled appointment.

The information I have provided is truthful & complete to the best of my knowledge. I assume responsibility for advising the clinician of any changes in my condition. Should I experience pain or discomfort during massage, or adverse response to nutrition, I will immediately inform the practitioner.

I understand that the I do NOT diagnose or treat medical disease/condition, nor prescribe; it is NOT a substitute for physician diagnosis and treatment.

We reserve the right to refuse service, as some health situations are beyond our care.

By signing below, you agree to all policies and information listed above.
Client Signature

Clear
Date

MonthDayYear
Date
Should be Empty: