New Client Intake

Your Name

Address


City, State, Zip Code

Phone Number

Alternate Phone Number

Email

Date of Birth
Month Day Year

Emergency Contact (Name and Telephone Number)

Please describe your primary problem/issue that you would like to work on.
(If you have received a diagnosis from a medical doctor, please state the findings).

Please describe a secondary problem (if you have one).

How long have you been experiencing your problems?
What types of treatment have you tried?

Please list any surgeries and the approximate dates.

Please list any medications and supplements that you are currently taking.

Are you using a pacemaker?
 Yes No

Do you have high blood pressure?
 Yes No

Waiver of release.

I accept full responsibility for...
By initialing the box below

Today's Date
Month Day Year