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Client History And Health Intake Form -Form Fill

Section One
Q1

Name*

First Name
Q2

Name*

Last Name
Q3

Date of Birth*

Date
Q4

Email*
Q5

Phone Number*
Q6

Emergency Contact Person*

First Name
Q7

Emergency Contact Person*

Last Name
Q8

Emergency Contact Phone Number*
Q9

How did you hear about us?
Q10

Do you have any medical conditions or concerns?*
Q11

Are you currently taking any medications? If yes, please list them below.*
Q12

Do you have any allergies? If yes, please list them below.*
Q13

Do you have any of the following?
Q14

Are you currently pregnant or breastfeeding?*
Q15

Have you recently or are you currently experiencing shortness of breath, chest pain/discomfort?*
Q16

Have you recently or are you currently experiencing swelling (edema)?*
Q17

Have you recently or are you currently experiencing concerns with bleeding?*
Q18

Do you have any concerns you would like ot discuss with the nurse?
Q19

Check all that apply:*
Q20

I grant permission to Primary Hydration & Wellness to take photographs or videos for the purpose of advertising and marketing.*
Q21

Your Signature*