Clinical Nutrition Center

NEW PATIENT INFORMATION FORM

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Please print clearly:

Name_______________________________________________    Date______________

Address______________________________________________    Apt.#_____________

City_______________________________    State____________    ZIP_______________

Shipping Address__________________________________________________________

________________________________________________________________________

Home Phone (____) ____-_________            Work Phone (____) ____-_________

e-mail address:  _______________________________________

REFERRED BY:_________________________________________________________

Occupation _________________________    Employer____________________________

Date of Birth__________________    Age ____ Sex: M/F    Height _____   Weight _____

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

Chief complaint (reason you are here): (use separate sheet if more room needed)

________________________________________________________________________

Previous treatments for this complaint___________________________________________

________________________________________________________________________

Other complaints or problems: (use separate sheet if needed)__________________________

________________________________________________________________________

Current medications/drugs being taken: (use separate sheet if needed)___________________

________________________________________________________________________

Are you currently under the care of a physician or other health care professionals?

(If yes, please give name and date of last visit):

________________________________________________________________________

Nutritional supplements you are taking:__________________________________________

Do you smoke, drink coffee or alcohol? (if yes indicate how much)

Cigarettes _______________    Coffee__________________    Alcohol________________

===============================================================

Office Use Only:

NewClient 7/01


 

 

 

 

Clinical Nutritional Healing Center

NEW PATIENT INFORMATION FORM

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Name:_______________________________________________    Date______________

HISTORY:

List any major illnesses (with approx. dates):______________________________________

________________________________________________________________________

List any surgery or operations with approx. date:___________________________________

________________________________________________________________________

Past Accidents or injuries:____________________________________________________

________________________________________________________________________

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Marital Status:   S   M   D   W              Name of Spouse_____________________________

Describe health of spouse:_________________________    Number of children if any _____

Name of Child                                 Age      Sex      Any physical conditions or concerns?

_________________________    ____      M/F    _________________________________            

_________________________    ____      M/F    _________________________________

_________________________    ____      M/F    _________________________________

Any family history of serious illnesses (circle those which apply): Cancer / Diabetes / Heart / Other        

Any household pets or other animals you or family members are in close contact with:

________________________________________________________________________

What can we do to make you happier?__________________________________________

________________________________________________________________________

 

SIGNED:_____________________________________________    DATE_____________