C l i e n t I n t a k e F o r m
Full Name:____________________________ DOB: ____________________
Address: __________________________________________________________
City: ______________________________ State: ______ Zip: __________
Phone #: _______________________Email: ___________________________
Occupation: ________________________
Emergency Contact: ____________________ Phone #: ____________________
Relationship:
Physician: ____________________________ Phone #: ____________________
Medical History
Health Conditions: __________________________________________________
Medications Being Taken: _____________________________________________
Please indicate any of the following conditions that you currently have:
.. headaches .. allergies .. arthritis, tendonitis
.. cancer .. TMJ .. abnormal skin condition
.. heart/circulation problems .. joint surgery .. high / low blood pressure
.. major accident .. varicose veins .. blood clots
.. neck / back injuries .. diabetes .. fibromyalgia
.. numbness
.. sprains, strains .. recent injuries
Explain Any Conditions You Have Marked Above:
