Client Intake
Email address
Name
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Address
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Phone #
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E-mail address
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Occupation
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Employer
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Marital Status
Who referred you to this office?
Your answer
Date of Birth
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Height
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Weight
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Number of children and ages
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Do you smoke?
Medical Marijuana?
Do you drink alcohol? How much, weekly?
Your answer
Do you drink coffee? How much, weekly?
Your answer
Present symptoms: What is your major complaint or condition you want to improve?
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How long has this been going on?
Your answer
Is this condition getting progressively worse?
Has there been a medical diagnosis?
Does this condition interfere with work?
Does this condition interfere with sleep?
Does this condition interfere with your daily routine?
What have you done to get relief?
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Are you now under medical/therapeutic treatment?
If "Yes", what type of treatment? And for what condition?
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List any other therapies you receive.
Your answer
List any medications (including aspirin) and nutritional supplements you are taking.
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Describe the exercise activities you engage in, include frequency.
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Please list any accidents or operations.
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Please add any additional comments regarding your health and well-being.
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Health History, Musculo-Skeletal
Health History, Skin
Health History, Reproductive System
Health History, Circulatory & Respiratory
Health History, Nervous System
Health History, Digestive
Health History, Other
Please list any additonal comments regarding your health and well-being:
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Client's Signature: I have stated all conditions that I am aware of and this informaiton is true and accureate. I will inform the care provider of any changes in my status.
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