New Client Forms
Clinical Nutrition Center
NEW PATIENT INFORMATION FORM
Page 1 of 2
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
Page 2 of 2
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_____________