Confidential Client Information

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CONFIDENTIAL CLIENT INFORMATION
Please Print
Name:________________________________________________
Date:____________________________
Street Address:_____________________________________________________________________________________
City / State / Zip:____________________________________________________________________________________
Email Address:_________________________________________
Birthday:_________________________
Cell Phone:_______________________
Home Phone:__________________
Work Phone:_______________
Occupation:__________________________________
Employer:_____________________________________
Emergency Contact - Name/Relationship/Phone:___________________________________________________________
Referred By:___________________________
Best Time / Day for Appointments:_______________________
********************************************************************************
Are you currently under the care of a physician, chiropractor, physical therapist, psychotherapist or other health care
practitioner? If Yes, Please Explain:____________________________________________________________________
__________________________________________________________________________________________________
Practitioner Name:_____________________________________ Phone: _______________________________________
Please sign here for your consent to contact:______________________________________________________________
If You Have Had Surgery Within Two Years, Detail Please:__________________________________________________
Please List ALL Allergies (food, medication, environmental, etc.):_____________________________________________
Please List ALL Medications/Supplements Currently Being Taken:____________________________________________
Please Circle If You Have ANY of the Following:
Arteriosclerosis
Asthma
Blood Clots
Breast Implants
Carpal tunnel syndrome
Colitis
Contact Lenses
Diabetes
Easy Bruising
Epilepsy
Fainting
Fibromyalgia
Headaches
Hemophilia
Herniated Disc
Hepatitis
Herpes I or II
High/Low Blood Pressure
HIV/AIDS
Kidney disease
Lupus
Marfan syndrome
Multiple sclerosis
Muscular dystrophy
Osteoporosis
Phlebitis
Pregnancy
Sciatica
Scoliosis
Tendonitis
TMJ syndrome
Tuberculosis
Tumors
Varicose Veins
Arthritis/location:________________________
Bursitis/location:__________________________________
Cancer/type: __________________________
Chronic Pain/location:_____________________________
Heart Condition/type:_____________________
Infectious Condition/type:__________________________
Neck/Spine Injury/location:________________
Skin Disease/type/location:__________________________

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