Therapeutic New Client Information

Therapeutic New Client Information
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

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

Area Code Phone Number
Mobile Number

Area Code Phone Number
Shipping Address

Street Address

Street Address Line 2

City State / Province

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

Month Day Year
Date
Age
Sex
Height
Weight
Emergency Contact
Emergency Contact Phone

Area Code Phone 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)

Cancer Diabetes Heart Disease
Please mark all conditions that apply to your personal health history.

Heart Disease High Blood Pressure Low Blood Pressure Varicose Veins Blood Clotting Circulatory Disorders Stroke Skin Conditions Allergies Cancer Epilepsy Seizures Multiple Scleroris Osteopenia Osteoporosis Scoliosis Migraine Headaches TMJ Dysfunction Neck Pain Shoulder Pain Mild/Low Back Pain Sciatica Hip & Knee Pain Bulging Disc Thyroid Disease Diabetes Hypoglycemia Carpal Tunnel Syndrome Thoracic Outlet Symdrome Fever (last 24hrs) Communicable Disease HIV Virus
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 Cigarettes Drink Coffee Drink Alcohol Type 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

Month Day Year
Date
Should be Empty: