New Client Intake Form printable pdf download

New Client Intake Form

The Health Improvement Center

New Client Intake Form

PLEASE PRINT CLEARLY AND ANSWER ALL QUESTIONS

Date________________

Name_____________________________________________________________

(

If under 18 years of age Parent/Guardian Name_______________________________________

)

Relationship to client____________________________________________________________

Address____________________________________________________________

City_____________________________ State______________ Zip____________

Cell Phone Number_____________________________

Home Phone Number____________________________

Email Address_______________________________________________________

How you hear about us:

[ ] Friend________________________________________________

[ ] Doctor________________________________________________

[ ] Internet Search

[ ] Facebook

[ ] Other_________________________________________________

Your Occupation_____________________________________________________

Age_________

Date of Birth_______________________________

Sex: M / F

Height__________

Weight__________

Overall health (circle one): Excellent / Good / Fair / Poor / Other_____________

Chief complaint (reason you are here):

__________________________________________________________________

Previous treatments for this complaint____________________________________

__________________________________________________________________

New Client Intake Form