Surveypoint

Q1

Name

First Name

Q2

Name

Last Name

Q3

Address

Street Address

Q4

Address

Street Address Line 2

Q5

Address

City

Q6

Address

State / Province

Q7

Address

Postal / Zip Code

Q8

Date Of Birth

Date

Q9

Sex

Q10

Phone Number

Q11

Work Phone

Q12

Home Phone

Q13

Email

Q14

Occupation

Q15

How Did You Hear About Us?

Q16

What Is Your Main Area(s) Of Focus/Your problems Area(s)

Q17

Do you have a chronic medication which we should know about?

Q18

If So Please List Them:

Q19

Do You Have Any Allergies To Latex, Medications, Herbal or Natural Supplements?

Q20

Do You Have or Have You Had, Any Changes In Medical History Recently?

Q21

Do you have Hearing aids, Pacemaker or Hormone Pellets (where), ormetal/medical devices implanted?

Q22

Explain:

Q23

Do you have type 1 or 2 Diabetes?

Q24

Please list all current medications including Vitamins:

Q25

Do you have or have you had Cancer in the last 12 months?

Q26

If yes, are you currently on chemotherapy?

Q27

Do you have a Thyroid Problem?

Q28

Do you have High Blood Pressure or Cardiovascular conditions?

Q29

Women Only, are you currently pregnant or nursing?

Q30

Please give us your current Weight and Height

Q31

What is your Ethnic Background?

Q32

Circle which applies to you:

Q33

re you currently dieting?

Q34

Explain

Q35

History of ColonProblems including protruding/distended belly?

Q36

Have you had any surgeries?

Q37

Infections Tumors Thrombosis/Phlebitis

Q38

Skin Diseases Autoimmune Disease

Q39

How many glasses of water do you usually drink?

Q40

How many cups of coffee do you usually drink?

Q41

How much alcohol do you usually drink?

Q42

How often do you eat fast food?

Q43

How much carbonation (ea. Soft drinks) do you usually take?

Q44

Do you use tobacco?

Q45

Recreational Drugs (narcotics)?

Q46

How is your stress level?

Q47

I agree that these forms have been completed truthfully and to the best of myknowledge/abilities.

Q48

Signature

Q49

Date

New Client History -Form Fill

Name

Name

Address

Address

Address

Address

Address

Date Of Birth

Sex

Phone Number

Work Phone

Home Phone

Email

Occupation

How Did You Hear About Us?

What Is Your Main Area(s) Of Focus/Your problems Area(s)

Do you have a chronic medication which we should know about?

If So Please List Them:

Do You Have Any Allergies To Latex, Medications, Herbal or Natural Supplements?

Do You Have or Have You Had, Any Changes In Medical History Recently?

Do you have Hearing aids, Pacemaker or Hormone Pellets (where), ormetal/medical devices implanted?

Explain:

Do you have type 1 or 2 Diabetes?

Please list all current medications including Vitamins:

Do you have or have you had Cancer in the last 12 months?

If yes, are you currently on chemotherapy?

Do you have a Thyroid Problem?

Do you have High Blood Pressure or Cardiovascular conditions?

Women Only, are you currently pregnant or nursing?

Please give us your current Weight and Height

What is your Ethnic Background?

Circle which applies to you:

re you currently dieting?

Explain

History of ColonProblems including protruding/distended belly?

Have you had any surgeries?

Infections Tumors Thrombosis/Phlebitis

Skin Diseases Autoimmune Disease

How many glasses of water do you usually drink?

How many cups of coffee do you usually drink?

How much alcohol do you usually drink?

How often do you eat fast food?

How much carbonation (ea. Soft drinks) do you usually take?

Do you use tobacco?

Recreational Drugs (narcotics)?

How is your stress level?

I agree that these forms have been completed truthfully and to the best of myknowledge/abilities.

Signature

Date